Active Drug Users

Introduction
Jørgen Anker, Vibeke Asmussen,
Petra Kouvonen & Dolf Tops
We are people from around the world who use drugs. We are people who have
been marginalized and discriminated against; we have been killed, harmed
unnecessarily, put in jail, depicted as evil, and stereotyped as dangerous and
disposable. Now it is time to raise our voices as citizens, establish our rights and
reclaim the right to be our own spokespersons striving for self-representation and
self-empowerment. (Statement by The International Activists who use drugs 30
April 2006, Vancouver, Canada)
In our society it is very rarely that people who use opiates, cocaine and
amphetamine or any combination of these and other substances are invited to
speak up and play an active role in the formulation of policies and practices in
the drug field. On the contrary, drug users are often treated as second-rate
citizens; not as subjects with rights, a voice and an identity, but rather as passive
recipients or objects of help or measures of control, punishment and discipline.
This publication aims to generate greater interest in and increase awareness and
knowledge about the existence of drug users as a group with an active voice. It
explores the spaces where such voices are given an opportunity to evolve with a
minimum of legitimacy and recognition. Through its various articles, therefore,
this publication seeks to provide an improved understanding of the possibilities,
limitations, advantages and dilemmas of user participation and user organisation.
Drug users obviously do not speak with one voice. In fact, they are a very
diverse group of people who are defined by one shared practice: their use of
substances, which are currently defined as illegal and dangerous. Apart from
being involved in a practice that is illegal, drug users vary in terms of age, sex,
class, ethnic origin, place of residence, source of income, etc. Obviously, there
are also characteristics that users share in common – the most basic of these
being that drug users by definition are regarded as criminals because they use
illegal substances. But many drug users also share the common fate of a rather
miserable life on the margins of society. On the other hand there are also many
users who do not live in misery, but who have permanent housing and a steady
job.
The group of people concerned are described using a number of different terms:
drug addicts, drug abusers, problem drug users, users of hard drugs, recreational
drug users, active drug users, people who use illegal drugs, etc. These terms also
carry with them different kinds of moral judgements, ranging from the
derogative drug addict or junkie at one extreme of the continuum to ‘people who
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use illegal drugs’, at the other. The latter is the term that is currently preferred by
activists in the field. We will return to these discursive dimensions and questions
of framing below. Here it suffices to note that this publication first of all focuses
on associations and specific practices or initiatives in the field that seek to
encourage the participation of people who are presently using so-called hard
drugs (e.g. heroine, cocaine, amphetamine), including opiate users in substitution
treatment.
Organisations for active drug user are not, however, the only actor on the drug
policy scene to speak up for drug users. Several of the articles in this publication
focus not only on organisations for and by active drug users, but also on
organisations run by former drug users, by drug users in substitution treatment or
by drug users’ relatives. In their contribution Brandsberg Willersrud & Olsen
show how these different kinds of organisations differ in their views on drugs
and drug users and how they struggle in public debates to gain the status of the
legitimate voice of drug users. Many of the contributions trace the historical
development of different organisations, explore their relationship with the
authorities, as well as the relationship between different but interrelated
organisations in the field. A further important aspect covered in this publication
is the involvement of drug users in different kinds of social services, which
offers interesting insight into drug users’ interaction with the official system.
The articles look at user participation both from the point of view of user
consultation, where users are asked their opinion and where they respond to the
demands expressed, and from the point of view of direct action, without any
clear demands on the part of the system.
In the Nordic countries, the first organisations for active drug users were formed
during the 1990s in Denmark and Norway, and in Sweden in the early 2000s. In
Finland, the first user-driven organisation was established in 2004 (see the
contribution by Tammi). These drug user organisations have been founded by
heroin users, they are run by heroin users and users in maintenance treatment,
and they also cater for active drug users, mainly heroin users. Representing
active drug users, the aim of these organisations is to raise issues where the
situation of drug users is considered unacceptable in relation to treatment
systems, control policies or the criminal justice system, for example. In this
sense the organisations serve as interest organisations and a mouthpiece for
active drug users. This publication aims to provide a deeper understanding of the
background for the emergence of these organisations, what they mean in a
broader sense, and how they help and empower drug users.
It is a guiding assumption in this publication that user organisations and the
patterns of participation they provide for have to be understood and studied in
close relation to the social, cultural and political context in which they emerge.
An important aim of this publication is hence to draw attention to some aspects
of drug policy and some trends in drug use in different national contexts that
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enable the emergence and continuity of drug user organisations. Examples are
included from Denmark, Finland, Norway and Sweden. To sharpen the
comparative focus, a contribution is also included on drug user organisations in
the Netherlands, where the first drug user organisations emerged much earlier
than in the Nordic countries.
Drug User Organisations: A Social Movement in
Formation?
Many of the contributions in this publication deal with associations and
organisations that are rather difficult to define and categorise: some of the terms
used to describe them include user organisations, client organisations, self-help
organisations, patient groups, interest organisations, voluntary organisations, and
social movement organisations. Indeed this field is characterised by great
diversity. At the same time, though, the wide range of terms also indicates that a
number of different analytical approaches are possible.
We suggest that many of the organisations described here indeed have a certain
family resemblance (Wittgenstein 1953) with phenomena that often are referred
to as social movements (calling attention to groups, questions, values and rights
of minorities that are often ignored or repressed by society). At the same time,
however, the concept of social movement may be misleading if it is used in its
traditional sense, i.e. as broad collective action that challenges existing relations
of power – which is how the concept has been used in the empirical analysis of
peace movements, labour unions, women’s rights movements, or civil rights
movements. The organisations described here are often much more introvert,
defensive and vulnerable than the powerful collective actors that are traditionally
described as social movements. Nonetheless they may still be important to the
participants themselves, to policy makers, and to the general development of
drug policies and drug users’ living conditions in the future.
Indeed the associations discussed and described here, seen individually as single
cases in their respective national political contexts, appear weak, fragmented and
marginalised. However the picture is very different if we look at them not as
separate and isolated national phenomena, but rather as part of a broader
transnational current. The idea of movement becomes more relevant when the
minor associations are considered as part of a more widespread trend that seeks
to address, question and even challenge the conditions and policies that define
and structure drug users’ lives. In this way, some of the associations in this
publication may be seen as being related to and stimulated by the emergence of
an international harm reduction movement that challenges the hegemony of the
discourse of a drug-free society (Bluthental 1998; Wieloch 2002; Tammi 2005).
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One argument for this unified view on drug user organisations is that they tend to
copy ‘repertoires of contention’ (Tilly 2002), applying similar forms of action to
gain attention to their problems. For instance, drug user organisations in the
Netherlands, Denmark, Norway and Sweden have copied the idea of awarding a
prize to someone who has made a particular effort to help drug users in the field
(see Tops, Anker in this publication). The different organisations also tend to
support one another, and the Danish Drug Users’ Union has directly supported
the formation of drug user associations of similar ideological persuasion in both
Norway and Sweden. Furthermore, there have been serious attempts to form and
strengthen international networks and cooperation between associations of active
drug users. Thus, at the annual International Conference on Drug Related Harms
in Vancouver on April 30 – May 4, 2006, representatives of user organisations
from all over the world gathered in a special session to agree on a common
statement and to discuss ways of stepping up their collaboration. Finally, some
of the organisations are members of international networks and organisations
that are committed to promoting harm reduction measures or the downgrading of
control policies. While we must not overestimate the extent and weight of this
cooperation, and indeed activists themselves tend to look upon their
organisations primarily as national or local efforts, it is interesting that the
phenomenon definitely is in evidence in many countries around the world, and
that in many others it is only just beginning to unfold. All social movements
develop through certain phases: they usually start as minor, more or less
invisible units or networks, and gradually gather momentum. This was also true
in the case of the movements mentioned above (Calhoun 1993).
Our argument is not that these groups and associations are social movements
proper; we acknowledge and emphasise that individual organisations should not
be misinterpreted as social movements (Eyerman & Jamison 1991). Nevertheless
many of the articles in this publication are inspired by social movement theory,
which is also applicable when exploring the character and processes of other,
smaller phenomena than the more powerful and well-known collective actors.
We find, in other words, that each organisation may be analysed through the lens
of social movement theory, and to underline this, we suggest that drug users’
associations can be seen as ‘social movement organisations’ (Zald & McCarthy
1987). Social movement organisations are singular organisations that form part
of a broader social movement. The purpose of applying this term is to signal that
the associations concerned are basically ‘just’ normal interest organisations
when studied individually. At the same time, though, they appear to form part of
something bigger, and they address a specific conflict in society. They strive to
gain recognition for the rights of a particular group of people and to gain
influence over and to change current drug policies. In other words, even though
they each apply rather pragmatic and non-confrontational strategies (with the
exception of the Dutch organisation), their broader and collective aim is to
change existing power relations and structures – and in this sense they may be
seen as social movements in formation. We therefore use the concept of social
8
movement organisations to describe these associations that are aimed at
changing local or national drug policies and that are – or claim to be – either
organised by or work for their constituency.
Understanding User Organisations and User Participation
The articles in this publication focus primarily on the particular forms of user
participation and associations that are found in the respective national contexts.
It follows that they are rather different in nature and deal with the issue of user
participation and association from various different angles. However, these
differences in themselves contain an important message in that they provide very
useful and important insights into the various dominant perceptions of user
participation and user association in the different national contexts. Even though
the organisations share many similarities in common, the articles clearly reveal
how sharply the ideas of drug user organisation differ in Sweden and Norway
from those in Denmark and the Netherlands, and that in Finland drug user
organisation is still very much in its infancy.
But how should these differences be interpreted? Is it possible to explain why
user participation and association assume so very different forms in countries
that in cultural, social and political terms are so closely connected?
Based on a careful reading of the articles in this publication, and inspired by
social movement theory, the following sections aim to provide a provisional
outline of some of the features that appear to influence the landscape,
opportunities and constraints of drug user organisations and participation. This,
we hope, will help to pave the way to new and more focused comparative studies
of user organisation and participation in which the relationship to national and
international drug policies can be explored in more depth.
Theories of social movements are generally concerned to understand and explain
why movements emerge and how they are organised, how they interact with
other actors in their respective field and why some movements succeed while
others fail. One line of social movement theory points at the importance of the
resources of social movement organisations (Zald & McCarthy 1987), other
theories emphasise the significance of political opportunities and political
processes (Tarrow 1994; McAdam, McCarthy & Zald 1996), others still
emphasise the processes of forming collective identities and the discursive
struggles in which movements are engaged (Melucci 1996; Johnston & Noakes
2005). These different theoretical leanings each contain important analytical
clues as to how the differences between drug users organisations in the countries
included here are understood. We do not propose to offer a full-blown
theoretical argument that gives full credit to the different theoretical stances.
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Instead, on a very eclectic and provisional basis, we present the dimensions that
appear to be important in the case of drug user organisations. In other words,
drawing on the thinking of social movement theory, we are aware of the
importance of resources, opportunities, openings and constraints and we seek to
take both institutional and discursive elements into consideration.
The field in which the organisations and opportunities for participation are
located, is absolutely crucial to the type of organisation and the kind of action
that is possible. Moreover, it influences the type of collective unity and selfunderstanding that is created among drug users. In the same way as the
organisation of labour structures the self-understanding, the action repertoire,
and the fate of the labour movement, the trends of drug use, the organisation of
services for drug users, and spaces of interaction among drug users are extremely
important to drug user organisations and to drug users’ participation.
Following from this, Rucht (1996) applies the concept of context structure to the
analysis of social movements. Context structure includes ecological elements,
i.e. conditions external to a given movement. The most crucial contextual
dimensions are the cultural, social and political. Seeking to translate these
dimensions into more specific empirical categories, we suggest that the three
main aspects that should be taken into consideration when examining and
explaining drug users’ struggles for legitimacy are the dominant ideological and
moral perceptions of drug use, the institutional contexts and patterns of drug use.
We elaborate on these dimensions below.
Institutional Patterns: Inclusive Welfare States – Excluding
Practices
Drug user organisation and drug user participation in the Nordic welfare state is
characterised by a number of odd constellations and contradictions. On the one
hand, a number of institutional and cultural practices provide opportunities for
drug users. On the other hand, specific institutional practices and some
overarching ideological and moral schemes tend to limit or remove the
legitimacy of drug user organisation and participation. Moreover, the situation
varies in the different countries, as will be discussed in more detail further on.
First, a few comments are in order on the nature of the welfare system. From an
international perspective it is important to emphasise that the Nordic welfare
states as well as the Netherlands both provide a minimum level of social security
to all their citizens. Even so, users of illegal substances often live a miserable life
in poor conditions. However the existence of a public social safety net means
that drug users, at least in principle, are guaranteed the satisfaction of their most
basic human needs.
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An illustrative example of the welfare system’s role as a source of income is that
many activists in the Danish Drug Users’ Union receive early retirement benefits
rather than social benefits. As their primary material needs are met, this
provides, at least in theory, an opportunity for them to engage in organisational
activities, such as in user organisations. The existence of a social security system
in other words ensures that the energies of drug users may be channelled into
activities that are not entirely a matter of physical survival. A number of specific
restrictions are occasionally applied to the group of drug users, however. In
Sweden, for example, there are requirements of remaining drug free for a certain
period of time in order to qualify for different kinds of assistance (e.g. housing
benefits). Differences of this kind between the countries are related to the moral
and ideological regimes, which dominate drug policies. Moreover, they may also
either facilitate or hamper drug users’ organisation and participation.
The Nordic welfare state system leans heavily on Social Democratic ideologies.
However, welfare states today are exposed to mounting pressures as a result of
the challenges of globalisation, new demographic patterns, and growing
neoliberal ideologies. These trends are also felt in the field of drug user
organisation and participation, where practices of social work as well as client
categories are gradually changing. Stenius (2006), who has studied the
citizenship and rights of substance users in Finland and Sweden, asks how two
countries with extensive treatment systems for alcohol and drug problems both
continue to have a group of substance users that is socially marginalised, in
terms of weak social networks, poor housing and exclusion from the workforce?
She concludes that both countries have changed into a society that no longer is
able to provide work for all its citizens. Instead, a minimum normative goal is to
produce independent consumers of goods and services, whose incomes also may
derive from the welfare system. In practice, however, several aspects, such as
legislation and the role assumed by the state, impacts the extent to which basic
human needs are met. As an illustrative example Laanemets refers in her article
to how different changes influence the field of drug treatment in Sweden, where
there are signs of a growing focus on decentralisation, market-related solutions
and a gradual withdrawal of the central state.
One important aspect that needs to be addressed when discussing drug users’
spaces for legitimate action is the shift in social political concepts from ‘client’
to ‘consumer’ (or ‘user’, as is the English translation of the Danish ‘bruger’, the
Swedish ‘brukar’, and Norwegian ‘bruker’, Finnish ‘asiakas’). Welfare policies
in general and social policies in particular have been influenced since the 1990s
by neo-liberal currents, new public management schemes and ideas of
empowerment, which also lie behind the new understanding of citizens as ‘users’
(in the sense of consumers) of welfare institutions such as treatment systems,
social security, hospitals, etc. (Asmussen 2003; Asmussen & Jöhncke 2004;
Bjerge 2005). In short, this social policy discourse is based on ideas of user
‘empowerment’ and active ‘participation’. In this understanding, citizens are
11
offered a greater degree of freedom, but also expected to assume greater
responsibility for managing their own life. The state, in this model, is
responsible for providing efficient and targeted services for users, and user
participation is one of the means for improving the effectiveness and efficiency
of services. In other words the Nordic social policy context – somehow through
the back door – advocates ideas and a rhetorical frame that enable drug users
legitimately to promote their wishes and to claim their right to substitution
treatment, for example. The social policy context has so to speak invited drug
users into an exchange on the question of how to deal with drugs in society. In
Denmark, the Ministry of Social Affairs has consistently provided economic
support for organisations for drug users and homeless people since the
mid-1990s. Nonetheless there are still critical voices which suggest that user
participation can also be seen as a particular form of control. Brandsberg
Willersrud & Olsen discuss this issue in their article, while Asmussen in her
contribution deals with some of the dilemmas of user participation.
The Nordic welfare states and the Netherlands have long traditions of involving
organised interests in the drafting of legislation and major reforms. Corporatism
was gradually established in the 20th century, enabling labour market
organisations to gain significant influence in the development of the welfare
state. Voluntary organisations have also traditionally held a relatively strong
position and degree of legitimacy in the Nordic countries, where they serve as
claims makers and service providers in specific areas of the social welfare
system, especially in the alcohol and treatment system (Stenius 1999). Compared
to the Netherlands, however, voluntary organisations here play a minor role in
the central fields of the social welfare system. In the Netherlands, with its strong
liberal tradition, drug treatment facilities are almost entirely provided by NGOs.
In the Nordic countries the main responsibilty for the provision of medical
treatment rests with the public authorities at central government, county or
municipal level. Nonetheless NGOs and private foundations are still important
suppliers of other forms of treatment. Even though these organisations are not
officially part of the state apparatus, they work closely with the public system
and depend heavily on public funding. As far as drug user organisations are
concerned, this is something of a dilemma because these organisations are
dependent on the authorities, which at once constitute a target for the
organisations’ actions. This implies a difficult balancing act and the
organisations risk becoming co-opted by and adapted to the political structures to
such a degree that they eventually lose their room for manoeuvre. In their
contributions Laanemets and Tops both draw attention to some of the dilemmas
and limitations faced by organisations when they enter into close cooperation
with the authorities or when they become heavily dependent on public funding.
However, even though the tradition of corporatism has been said to clearly
favour a particular kind of interests (Hernes 1987), it also gives rise to a
particular administrative and democratic practice in which organised interests
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are given a legitimate right to have a say in public inquiries. This is an issue that
Johnson addresses in his article with reference to particular interest
organisations’ influence on decision-making processes in Swedish drug policy.
He concludes that drug user organisations have in fact had only very limited
influence on Swedish drug policy, a trend that has continued (or worsened) with
the further reinforcement of control policies. In his opinion, the emergence of the
Swedish Users’ Union is not an outcome of increased openness or better
opportunities for participation, but rather of neglect and limited opportunities for
interest representation.
National Patterns of Drug Use
Another feature that influences drug users’ opportunities for organisation and
participation apart from the dominant ideological and moral perceptions of drug
use and the institutional contexts, is the pattern of drug use. Specific practices
and traditions of drug use – which are obviously linked to the nature of drug
policies – provide the basic condition for users to identify shared interests
related to drug use and representation in relation to the authorities and the
surrounding society.
The countries described in this publication all represent different trends and
histories with respect to drug use and perceptions of drug use. These trends are
crucial to understanding the emergence of user organisations and the specific
demands placed on the services provided for drug users. The lack of
organisations for active drug users may for instance in the case of Finland be
explained by the absence of a ‘tradition’ of heroin use. It seems that the presence
of particular treatment facilities can often support and promote the establishment
of drug user organisations. The following outlines some of the recent trends in
drug use and drug policy in Denmark, Finland, Norway, Sweden, and the
Netherlands.
Together with the rest of Europe, the Nordic countries saw increased levels of
drug use in the 1990s (EMCDDA 2005, 11–12). In all countries the fastest
growing category seems to be represented by poly drug use, but some substance
specific comments can nonetheless be made. In Denmark heroin is reported to be
the primary drug for about 60 per cent of those seeking treatment (National
Report to the EMCDDA, Denmark 2004). Injecting heroin use has been going on
in Denmark for several decades, and even though this is still the most prevalent
form of use, smoking heroin has become increasingly common among those
entering treatment. In Norway, too, drug users who seek treatment are primarily
intravenous heroin users (National Report to the EMCDDA, Norway 2005), and
again injecting heroin use has been going on for decades. In Finland and Sweden
there is a long tradition of intravenous amphetamine use. Until the 1990s opioid
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use was virtually non-existent in Finland. Recent estimates of problem drug use
around the turn of the century put the proportion of amphetamine users at around
70–75 per cent (Partanen et al. 2001). Among those seeking treatment for
injecting opioid use in 2004, 27 per cent sought treatment for buphrenorphine
use, and only 3 per cent for heroin use (Clients in Substance Abuse
Treatment/Stakes, 2004). In Sweden large numbers of users who seek treatment
are on amphetamines, but the figure for those using heroin is rising and is now at
almost the same level as amphetamine use (National Report to the EMCDDA,
Sweden 2003–2004). In the Netherlands, heroin has been regarded as the most
problematic drug ever since its introduction on the black market in 1972,
although since 1990 it has been accompanied by cocaine. In 2003, the number of
heroin clients registered in ambulatory treatment showed a tendency to decrease,
while the number of cocaine clients was on the increase. The proportion of
amphetamine clients remained steady (VWS 2005).
There are organisations for active drug users, mainly heroin users, in the
Netherlands, Denmark, Norway and Sweden. Finland has organisations that are
run by relatives of drug users, but none run by active users themselves. In the
past year or so, however, small groups of users have been forming. Against the
background of the different drug trends and traditions in the Nordic countries it
is hardly surprising that Finland did not have any such organisations until 2006.
As Tammi explains, it takes time for the necessary critical mass to form, and
since it was not until the late 1990s that hard drug use really began to expand in
Finland this is still a novel phenomenon. Furthermore, the mean age of drug
users in Finland is lower than in the other countries concerned. Young people
with a relatively short ‘drug user career’ can therefore hardly be expected to
have gained sufficient experience and political awareness of the drug field to
perceive a need for collective action.
Yet if we want to gain a more in-depth understanding of what facilitates or
obstructs the emergence of drug user organisations, we cannot simply explore
trends of drug use in isolation from the ideological and moral perceptions of
drug use, which are largely reflected in national drug policies.
Moreover, it appears that drug user organisations often tend to emerge in the
wake of developments in the treatment system. The services and intentions of the
treatment system tie in closely with the ideological and moral principles that lie
behind national drug policies. In the next section, we first provide a short
overview of the most salient features of national drug policies, and then return to
the question of how the treatment system is connected to drug user organisations
and participation.
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National Drug Policies, Harm Reduction and Substitution
Treatment
The Nordic countries are often said to represent a particular type of welfare state
model (Esping-Andersen 1990). However, as far as drug and control policies as
well as drug users’ opportunities for legitimate action and participation are
concerned, there are certainly many differences between these countries
(Hakkarainen, Laursen & Tigerstedt 1996; Christie & Bruun 1985). Drug
policies consist of different domains (control, treatment and prevention) that
often contradict one another, mainly since they are often based on different – and
often contradictory – drug policy ideologies. Basically, a restrictive control
policy is typically associated with ideas of abstinence and a drug-free society in
the realms of treatment and prevention. A liberal control policy, on the other
hand, fits more easily with ideas of harm reduction.
Norway and Sweden have traditionally had the most restrictive drug policies in
the Nordic countries, pursuing ideas of a ‘drug-free society’. Harm reducing
initiatives, then, have been virtually non-existent, at least until recently.
Denmark, on the other hand, has until today had the most liberal drug policy,
both with respect to its control policy and the existence of harm reducing
initiatives alongside drug-free treatment. Finland differs from the rest of the field
in the sense that up to the 1990s, it had only minor drug problems. Officially, the
goal was to prevent drug use and minimise the supply of drugs. The country’s
drug policy was mainly control-oriented. Minimal attention was given to the
treatment of drug abuse (Hakkarainen & Tigerstedt 2005). The Netherlands has
no mechanisms in place to try and eliminate drug use, and the official policy for
almost 20 years has been one of harm reduction. Instead, the main focus has
been on the (wholesale) trade of hard drugs and cannabis (Tops 2001). In the
1990s all the Nordic countries (and indeed northern Europe more generally) saw
changes in patterns of drug use as well as an increased public awareness of the
serious consequences of problematic drug use. This prompted new responses to
drug use and new directions in drug policy. Still, the main strategies vary
according to the ideological climates and the political compromises reached in
the respective countries.
Today, drug policies seems to be moving towards an increased focus on
substitution treatment or ‘medicalisation’ even in those countries that
traditionally have had a restrictive drug policy (Skretting 2006). At the same
time, however, there are no signs in the Nordic countries of their intending to
downgrade the control against drug users. In Finland, for instance, the policy has
moved forward on a dual track of both increased control and increased harm
reducing measures (Hakkarainen & Tigerstedt 2005). In the past 3–4 years
Danish drug laws have also become more restrictive. At the same time there is a
strong tradition of methadone maintenance treatment. Recently a three-year
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methadone trial with extended psychosocial support was initiated as an
alternative to a heroin trial. An important part of this trial was to integrate user
participation in treatment facilities in order to empower drug users and
encourage them to take part in their own treatment. In this publication Asmussen
discusses the different forms of user participation implemented in the trial and
addresses the question as to how far these initiatives provide opportunities for
drug user participation in their interaction with the treatment system. Norway
has continued to pursue a restrictive drug policy and it is now moving towards a
more lenient criminal policy. As Brandsberg Willersrud & Olsen point out in
their article, however, the increasing number of drug-related deaths in the 1990s
meant that the country began to lean more towards a harm reducing drug policy.
Substitution treatment is today an integral part of the treatment offered to drug
users in Norway. Even Sweden, which has taken the most restrictive stance on
medically-assisted treatment, introduced substitution treatment with
buprenorphine in 1999.
The articles by Anker, Brandsberg Willersrud & Olsen, Palm and Tammi all
show that the first initiatives to establish drug user organisations or organisations
that speak up for active drug users often takes place within or in close
connection with substitution treatment facilities. The organisations raise critical
questions with respect to the treatment provided, for example the availability of
substitution treatment in general, the control of supplementary use of illegal
drugs, as well as other forms of control measures practised by the treatment
institutions. In Norway the first user organisation MIG-96 started up in
connection with the country’s first methadone trial, with the aim of improving
the quality and availability of methadone treatment in general (Brandsberg
Willersrud & Olsen). In Denmark, the Danish Drug Users’ Union (DDUU) was
established in 1993 following the closure of a popular activity centre for
methadone users (Anker). In Finland, the Association for Support of People with
Opiate Addiction (ORT) campaigned between 1997 and 2003 to increase the
availability of treatment for opiate addicts and generally to improve the quality
of treatment. The first user-driven organisation, Support for Substitution
Treatment Association (KT), consisting of four clients of a substitution treatment
clinic in Southern Helsinki, was established in 2004 (Tammi). The Swedish
Drug Users’ Union was set up in 2002, and one of its main criticisms has been
against the strict formula for substitution treatment in Sweden (Palm). The first
organisation for drug users in the Netherlands was established in Amsterdam in
1975. In its first year the organisation advocated an alternative ‘user-friendly’
treatment approach. Soon, however, it shifted its attention to campaigning for a
change in the national drug policy on hard drugs, which was seen as the main
cause for the problems encountered by drug users (Tops).
Apparently, there is some kind of connection between the establishment of
substitution treatment programmes and the emergence of drug user
organisations; but how can this connection be explained? We suggest that the
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introduction of harm reduction initiatives in general, and substitution treatment
programmes in particular, open up opportunities for organisation and user
participation among drug users.
First, in a situation where the aim of a drug-free society dominates and rules out
any other pragmatic options, there is very little tolerance for and acceptance of
alternative voices. In a context of control, repression and zero tolerance, drug
users will have only very limited room to manoeuvre as long as they continue
using drugs. This situation seems to have prevailed in Sweden for many years,
and the only legitimate and visible mouthpiece for drug users have been
organisations of former drug users or associations of relatives. There must be a
certain acceptance of harm reduction initiatives in order for drug user
organisations to emerge.
In both Denmark and Finland, relatives of drug users and medical doctors have
been important advocates for harm reduction initiatives and substitution
treatment programmes. They have sought to document the need for substitution
treatment, they have highlighted the right of drug users to receive treatment, and
they have occasionally sought to change practices themselves, for example by
providing methadone to drug users through acts of civil disobedience (see
Tammi and Anker in this publication). These groups are important allies to drug
user organisations, and they often appear to be important because of their ability
to mobilise and channel resources (economic, skills, strategic considerations,
influence, etc.) to groups of drug users, thus enabling the subsequent formation
of organisations.
Moreover, once established, substitution treatment programmes create a closer
and more formalised relationship of interaction between ‘the system’
(authorities) and drug users. A number of other user organisations that have
emerged in relation to the social welfare system, are based on categories that
from the outset were defined and invented by the system. These categories (e.g.
psychiatric patients, the disabled, the elderly), after being subjected to the
development of specific policies and services, have then slowly come to form the
basis for acts of resistance and the formation of collective identities (Williams
1999). In other words, these categories – and the subsequent collective actors –
are to a great extent created and structured by the system. Gubrium and Holstein
(2001) have called the identities institutional selves. This, we contend, is also the
case with drug user organisations. Most drug user organisations are directed
towards different levels of authorities in the drug policy field, they define
themselves and their actions in relation to the authorities, and it is also from the
system that they seek recognition and legitimacy as collective actors. This
process is enabled by the creation of substitution treatment programmes.
Substitution treatment programmes create a shared space and a shared point of
reference where drug users are expected to conform to the previously defined
17
rules and requirements. Whereas life as a drug user, without any formal
relationship to the system, does not necessarily bring drug users together, the
rules, physical space and interaction with health and social workers involved in a
substitution treatment programme become a shared experience and an
opportunity to interact as a group with particular characteristics. In this way drug
users feel they are confronting the same opponent, and thus also have an
identifiable target for their claims.
Finally, substitution treatment programmes draw the drug issue closer to the
medical discipline, converting as they do the drug use into a matter of illness
rather than just a moral issue. In other words, substitution treatment programmes
also help to afford the drug user the status (and rights) of a patient who is
entitled to claim his or her rights, proper treatment, and recognition and respect
as a human being. Drug users may still object to this perception of drug use as an
illness, but our point is that the hegemony of moral judgements loose strength
when drug users become more closely connected to the health system, as patients
rather than as social outcasts.
Struggling for Legitimacy in a Climate of Ideological and
Moral Condemnation
People addicted to drugs are a small minority, and the majority of people in
society do not share their experiences. However the ‘drug issue’ has been
regarded as a very serious social problem for many decades now, and in that
respect it has been of great interest to society. For drug user organisations, the
challenge is to frame the problems of their constituencies in such a way that they
resonate with cultural patterns in the population and are easy to recognize.
The way that drugs and drug problems are conceptualised in national drug
policies depends closely on the choice of language in describing these problems.
An example is provided the Danish government’s use of language in the recent
publication The Fight against Drugs - action plan against drug abuse (2003).
The use of ‘fight’ here resembles the American drug rhetoric of ‘war on drugs’.
The choice of ‘drug abuse’, then, implies a particular moral attitude towards
drug use, including a sense of ‘irresponsibility’, ‘weak personality’, ‘lack of selfdiscipline’, ‘lack of motivation’, etc. Decades of liberal Danish drug policy have
now given way to a more repressive policy – and at the same time to rhetoric
traditionally used in connection with repressive drug policies.
Drug use in general is constructed and perceived as something negative and
dangerous, not only to the individual concerned but also to society at large, and
it seems extremely difficult to shrug off the negative image of drug user that
follows from this understanding (Christie & Bruun 1985; Gossop 2000/1982,
18
Reinarman & Levine 1997). Drugs have become a powerful metaphor with
(extremely) negative connotations. Drug addiction, drug abuse and even drug use
are blamed for the worsening of – or even seen as synonymous with – different
traits such as criminality, instability, untrustworthiness, violence, mendacity, a
weak personality, bad temper, irresponsibility, etc. Such is the power of the
metaphor that drug users are identified by society as people with particular traits,
regardless of whether or not this is the case.
It is important to underline that drugs and drug use may have devastating, even
fatal consequences. People get into serious problems by using drugs, and some
drug users can in certain situations be identified with the traits described above.
However it is important to recognize that the general perception of drug use is so
pervaded by moral and ideological judgements that other perceptions of drug use
have great difficulties gaining legitimacy. As is shown by the articles in this
publication, these negative and moralising attitudes may also hinder drug user
participation. In an environment of control and moral condemnation, drug users
will often hesitate to openly admit they are drug users. They therefore often lack
spaces of legitimacy where they could take their first steps of organisation. Palm
discusses constructions of the ‘user’ by the Swedish User Organisation (SBF) in
relation to the limited space and possibilities to act in the name of active drug
users.
One of the aims of organisations for active drug users is to try and change the
existing, denigrating perceptions. Stigmatisation and marginalisation are among
the key issues addressed by these organisations. In this publication Anker, Palm
and Brandsberg Willersrud & Olsen discuss the different strategies applied by
drug user organisations to fight stigmatisation and marginalisation. One of those
strategies is to use concepts that avoid negative connotations. Therefore, rather
than talking about ‘drug abusers’, ‘drug addicts’ or ‘junkies’ (Denmark &
Norway: ‘narkoman’, Sweden: ‘knarkare’, Finland: ‘narkkari’), which all carry
the negative associations described above, most drug user organisations prefer
the more neutral term ‘drug user’. Their rationale is that a change in language in
the long run will bring about a change in meaning and hence a change in
perceptions of drugs as well as drug use. Besides strategies to overcome
stigmatisation, another probably more immediate effort to alter the negative
perceptions of drug users is by demonstrating their ability to run or participate in
running an organisation, to take part in meetings, keep agreements, etc. A related
question is whether drug user organisations should be organisations by or for
drug users. If run solely by active drug users, they will be exposed to
vulnerabilities due to the usually unstable lifestyle of drug users and the
repression of drug policies. This is basically a matter of the constituency of drug
user organisations and whether these consist of drug users who are still using
illegal drugs or of former drug users.
19
As is shown in this publication, different solutions are applied in order to
overcome problems related to drug user organisations’ constituency and
strategies. The way that organisations are run seems to be in a constant state of
flux and their strategies to be constantly re-negotiated. The issue of interest
organisations’ recognition and legitimacy is crucial, and an enormous amount of
energy is invested in pursuing that legitimacy. On some occasions, drug users
even compete with former drug users, with different groups all claiming to speak
on behalf of all drug users, as discussed by Brandsberg Willersrud & Olsen and
others. In the process of gaining recognition, new organisations are founded at
the same time as others are closed down, as outlined by Tammi in this
publication.
The survival and success of drug user organisations is never a matter only of
suitable strategies, but merely an indication of how the messages articulated are
heard and interpreted in a certain place and at a certain time. Therefore, as
discussed above, the impact of the institutional contexts, national drug policies,
patterns of drug use and dominant ideological and moral perceptions of drug use
all contribute to the existence and survival of user organisations. The emergence
of user organisations in the Nordic countries during the past decade also show
that these are no isolated events, but part of a broader movement and network.
Networks and what Melucci (1996) has called the invisible phases of social
movements are crucial to the development and understanding of social
movements. They provide the necessary foundation for meaning work, and they
are basically a prerequisite for the mobilisation of resources and for the creation
of shared understandings of aims and strategies. So perhaps the fragmented
initiatives of association and user participation – the efforts of the more or less
invisible networks – that we are witnessing today, may prove to be an initial
phase of a broader organisation and self-awareness among marginalised groups
of the welfare society?
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22
Who is the Expert?
Patient Groups and Finnish Substitution Treatment
Policy
Tuukka Tammi
Introduction
Based on their literature review, Hunt and Barker (1999) conclude that the
client’s experience of drug treatment is the single most uncharted area in drug
treatment research. Although substitution treatment (with methadone) is one of
the most investigated treatment modalities, research on clients’ perceptions and
experiences is virtually non-existent: researchers have been more concerned with
documenting the use and efficacy of treatment services and less concerned with
the clients’ perspective on the treatment they receive (Hunt & Barker 1999, 129–
131). However, the rare – often ethnographic – studies that have been conducted
on the methadone clientele show how clients are not passive recipients, but
instead active participants within the world of the clinic, and they may
successfully resist the surveillance as well as the new particular identity offered
to them as clients or patients (ibid.; Skoll 1992; Fraser 1997).
This article contributes to the limited research on client experiences of
substitution treatment. It describes the claims-makings of two Finnish client
organisations with regard to substitution treatment. These organisations were
born out of dissatisfaction with the slow progress and poor quality of
substitution treatment in Finland at the turn of the millennium: they are an
association for the support of opiate addicts (Opiaattiriippuvaisten tuki ry; ORT)
and an association for the support of substitution treatment (Korvaushoidon tuki
ry; KT). As will be described below, both of these groups started out in response
to a sense of being deprived of something as patients.
Until the mid-1990s, both the use of drugs and related problems were still
relatively marginal in Finland when compared to most other Western European
countries. The situation then began to change: not only experimentation but also
intravenous drug use and related harms began sharply to increase, which also
drove up the demand for treatment and drug-related crime (Partanen & Metso
1999; Virtanen 2005). This resulted in various mobilisations in the drug policy
field: committees and working groups were set up, action plans were drafted, and
various professions called for more resources. As a consequence, many concrete
changes followed (for more on these changes, see Tammi 2002, 2005a & 2005b;
23
Hakkarainen & Tigerstedt 2004). One was the dramatic change in substitution
treatment policy, which saw the number of clients increase from just a few
patients in the mid-1990s to almost 1,000 in 2005.
The rapid changes have been explained not only by reference to the changing
drug situation, but also by the forceful campaigning of a medical lobby for
substitution treatment. Initially this lobby consisted of just a couple of medical
doctors, most notably Pentti Karvonen, a private MD whose liberal practice of
buprenorphine prescription first gave rise to official warnings, then to his being
struck from the medical register, and eventually to a prison sentence for illicit
trafficking and distribution of buprenorphine to his clients. At the same time as
this drama was unfolding, the lobby for substitution treatment continued to grow
and even many official players in the drug treatment policy field became more
favourably inclined towards the new practice. Particularly influential in this
regard was the advocacy of substitution treatment by Osmo Soininvaara, the
Green Party Minister of Social Affairs, and Mikko Salaspuro, a prominent
medical expert (Hakkarainen & Tigerstedt 2005).
While at the beginning of the 1990s expert committees on drug treatment
(Report on arranging treatment for addicts in Helsinki 1991; Working group
report on developing medicinal treatment of opioid addicts 1993) had still taken
a negative stance on substitution treatment, by the end of the decade working
groups on drug treatment (Working group report on developing drug treatment
2001; Working group report on developing medicinal treatment of opioid addicts
2001) as well as general drug policy strategies (Drug Strategy 1997 – Report by
the Finnish Drug Policy Committee; the 1998 and 2000 Government Decisionsin-Principle) were advocating a widening of substitution treatment. Funding has
also been made available to local authorities for the start-up of these treatments.
Needless to say, when we look at the range of actors who took part in this policymaking process, we find that the field was predominantly authority- and expertdriven: the actual target of the policy, the drug user, had a very little role in
policy-making. This, of course, does not mean to say that users have no views
and opinions on how the policies should be developed. In what follows, I give
voice to the two user groups mentioned above. My data consist of documents
produced by the groups concerned as well as of interviews, discussions and email exchanges with group members. I first provide some background
information on the groups’ formation, composition and activities, and then move
on to their claims-making. I conclude with a general discussion of drug policy
and user participation in Finland.
24
Evolution and Activities of the Patient Groups
The Partisans: Association for the Support of Opiate Addicts
(Opiaattiriippuvaisten tuki ry; ORT)
ORT worked in 1997–2003 to “increase the availability of treatment for opiate
addicts and generally develop the quality of these treatments”. The group
lobbied particularly for buprenorphine-based substitution treatment, this being
the drug with which the above-mentioned doctor Karvonen had treated his
patients. ORT was keen to adopt the so-called “French system” 1: in France
buprenorphine has become the main form of substitution therapy, with some
70,000–80,000 (OFDT 2004) people being prescribed it, often by private
doctors. In general, ORT wanted to “improve the way that these people who
wanted buprenorphine were treated” and “to increase lay people’s knowledge
about the fact that drug use is a disease that leads to many other difficulties (such
as crime, domestic violence, use of child protection, infectious diseases, etc.) if
not treated properly”.
As mentioned, one of the main advocates of substitution treatment in Finland
was a private MD who readily prescribed buprenorphine to opiate users in the
Helsinki area, until the National Authority for Medicolegal Affairs (TEO) in
May 1997 withheld his rights to prescribe these drugs and eventually struck him
off the medical register. The formation of ORT was ultimately prompted by this
decision. At the time of the decision (according to ORT) the doctor had some
200 patients who were suddenly deprived of their medicine. A group of parents
and other people close to these patients approached the relevant authorities and
treatment organisations in an attempt to get the treatments re-started. However,
they soon noticed that the authorities “didn’t know anything about the prevailing
problems and their attitude was very ignorant”.2
When the association was started in 1997 it had a membership of ten. Next year
the number increased to around 30, at which level it remained until its
dissolution in 2003.
Who were these people? During the first two years the association consisted of
drug users’ support persons and other closely related persons, in 1999 and 2000
they had also other “support members”, and from 2001 onwards ORT also
reported having among its members “ex-users who are in treatment”. 3 So
1
2
3
The term was used e.g. in a letter from the ORT to the Ministry of Social Affairs and
Health, dated 17.12.1998. About the French substitution treatment policy, see Bergeron
(1999).
ORT, Report on activities 1997.
ORT, Reports on activities 1997–2003.
25
although the association was open to (ex-)users, ORT was not run by users but
rather by their parents or other people close to them; therefore the association
could be regarded as a semi-user group.
The group had some success in its efforts to break into the formal field of drug
policy-making. For instance, their opinions were consulted by the Ministry of
Social Affairs and Health when the regulations on substitution treatment were
updated; they testified to an expert working group on substitution treatment; they
were invited to deliver a speech at a high-level conference on “evidence-based
drug treatment” in 19994; and in 2001 they also received funding from the state
gaming monopoly RAY, the main source of NGO funding in the field of social
welfare and health, for a two-year project. In other words, ORT achieved
recognition as a valid claims-maker in the field.
In spite of this relative success, ORT was closed down in 2003. In the words of
the ORT chairperson, this was done “in frustration after banging our heads
against the wall in talking about heroin users as worthy human beings, about
their rights to treatment, equality with other patient groups and so on”.5
However, during its six years of existence the group had actively advocated its
cause. It wrote newspaper pieces, sent letters to politicians, submitted petitions
to officials responsible for drug treatment, and maintained its own website. To
give a few examples, one of the first petitions was submitted in 1997 when the
Ministry of Social Affairs and Health had issued its first regulation on
substitution treatment (1997:28). ORT submitted a list of demands on how the
regulation should be amended. Its demands included a significant increase in the
number of substitution treatment places; the allocation of resources and
responsibilities to private clinics; a shift in emphasis from inpatient to outpatient
treatment; the separation of drug user clients from mental health care patients;
the setting up of drug-free units and needle exchange services in prisons; patient
involvement in their treatment and medication; and the removal of the threemonth ceiling to treatment periods.
One of ORT’s biggest efforts took place in August 1999 when they filed a
complaint to the parliamentary Ombudsman together with the ombudsman for
clients of substance abuse care, who provides free legal counseling for clients in
drug or alcohol treatment.6 The Parliamentary Ombudsman is an institution to
4
5
6
26
These so-called consensus conferences are arranged by the Finnish Medical Society
Duodecim together with the Academy of Finland; the idea is to offer a forum for
discussion between medical scientists and decision makers around a given medical
problem and treatment alternatives.
Letter from the chair of the ORT to the author, dated 13.7.2004.
The ombudsman is a project funded by the RAY, the national gambling monopoly, and
it is being run by A-Kiltojen liitto (“A-Guilds Union”) which is a wide network of local
associations of the clients of “A-clinics”, the outpatient treatments units for substance
abusers. In practice, this association focuses purely on people with alcohol problems, but
the above-mentioned service has been actively used also by the clients in drug treatment.
whom citizens can file complaints if they suspect that a public authority or
official has breached the law or failed to perform their duties.7 Briefly put, the
content of the complaint was that the cities of Helsinki, Vantaa and Espoo (the
latter two are neighbours of Helsinki) had failed to organise buprenorphinebased treatments according to patients’ needs, and that this was a contravention
of legislation. The decision from the Parliamentary Ombudsman came more than
two years later (dated 31 Dec, 2001) and was based on replies from the three
cities as well as on three statements by the Ministry of Social Affairs and Health.
This process had forced the officials to give an answer to ORT, although the
passage of time and changes in substitution treatment policy had already
resolved part of the problem by the time that the Ombudsman’s decision finally
came through. By late 2001 buprenorphine-based treatments were increasingly
accepted and offered, but the Ombudsman took the view that at the time of the
complaint (1999) ORT had been in the right: demand had exceeded the supply of
substitution treatment with buprenorphine. Although the Ombudsman was of the
opinion that the patients had a fundamental right to treatment, she took a
negative stand on the patients’ subjective right to choose what they regarded as
the best treatment (i.e. substitution treatment with buprenorphine); according to
the decision the patients do have the right to refuse a particular treatment, but not
to choose another treatment instead. This stand was a major setback for ORT
who from the outset had maintained that they and the patients were the best
experts, based on both patient experiences and the latest scientific research from
abroad.
Patient Activism from Inside: The Association for the Support of
Substitution Treatment (Korvaushoidon tuki ry; KT)
Support for substitution treatment (KT) is a new association that is based on the
same kind of underlying idea as the SBF (Svenska Brukarföreningen) in Sweden
and the DDUU (Brugerforeningen for Aktive Stofbrugere) in Denmark. It has
been set up by patients themselves around the inadequacies of substitution
treatment with the aim of influencing treatment from within, from the client
perspective. Although the group is still very small and young (indeed it is not yet
clear whether it will survive the early dispute described below), it deserves to be
introduced here because it reflects the changes that have taken place both in the
drug (treatment) policy field and in user activism: just a few years ago an
association like this would not have been possible because both the target of
action (the content of substitution treatment) and the actors (patients in
substitution treatment) did not exist in Finland. While ORT was still about
influencing the system from the outside and calling for the provision of
buprenorphine-based substitution treatment, the setting in the case of KT is
7
The Parliamentary Ombudsman is based on the Constitution of Finland and pays special
attention to the implementation of fundamental and human rights.
27
different: here the aim is to influence the existing substitution treatment system
from within, as patients who have been admitted to treatment. Changes in the
policy field have made possible new forms of collective protest.
KT was established in spring 2004 by four clients of a substitution treatment
clinic in southern Helsinki8. The overall aim of the association is to “improve the
quality of treatment and to promote treatment practices that respect drug users as
equal and normal human beings”. The initial impetus for the association was the
sudden decision to change the founding members’ substitute drug without
consulting their opinions as patients, despite the side-effects that the patients
reported to the treatment personnel. The drug was changed from Subutex to
Suboxone, which is a combination of buprenorphine and naloxone. Naloxone is
a drug that has been used to help users who have overdosed as it should block
the effects of medicines and drugs like methadone, heroin, and morphine. The
idea of combining naloxone with buprenorphine is to stop people from injecting
the drug: according to the manufacturer’s website, “The naloxone in Suboxone is
likely to precipitate withdrawal symptoms when injected by individuals
dependent on heroin, morphine, or other full opiate agonists. Therefore, it is
assumed that Suboxone would be less attractive to ‘street addicts’ and less likely
to be diverted. Therefore, it is strongly recommended that Suboxone be used
whenever unsupervised administration is planned.”9 In Finland, too, street-use,
i.e. injecting buprenorphine has become quite common and attracted criticism as
an undesired effect of the expansion of substitution treatment – this was the
official reason for the switch to Subuxone.
KT rejected this official argument for the change of drugs and countered it with
its own experience-based information. In a petition to the doctors-in-charge of
four substitution clinics, they stated: “We, as patients, feel that we are being
used as forced, unpaid laboratory animals. If our situation is compared with
some other patient group (e.g. diabetics, epileptics) for whom a new drug is
prescribed; if the new drug did not help them, this would hardly mean that
instead of going back to the old drug the only option would be to try another new
but useless drug or quitting treatment”. The alternative to Subuxone offered by
the clinic was methadone, which KT members considered too strong and
addictive compared to buprenorphine.
To date, KT’s activities have consisted of writing petitions to experts and
officials as well as meeting with their counterparts and others concerned (such as
representatives of the pharmaceuticals company that sells both buprenorphinebased drugs). Like ORT, KT invokes the Act on the Status and Rights of Patients
8
9
28
Touting for new members has been going on since but according the funding members
this has been difficult because other patients fear they will be sanctioned if they’ll join
the group (Petition, dated 27.4.2004).
http://www.suboxone.org/Suboxone/patients/faqs.htm &
http://www.suboxone.org/Suboxone/phys/faqs.htm
in support of their demands. At the core of their argument is section 6 of that
Act, according to which “The patient has to be cared for in mutual understanding
with him/her. If the patient refuses a certain treatment or measure, he/she has to
be cared for, as far as possible, in another medically acceptable way in mutual
understanding with him/her.” In addition to the adverse side-effects from and
ineffectiveness of the new drug, KT reported that, contrary to the thinking of the
officials, Subuxone was being sold and injected in the streets just like Subutex.10
KT members claim that the motive for the change of drugs is ultimately of a
political nature and not based on medical knowledge; they report that despite
repeated requests for research information on the side-effects of Subuxone, no
answers have been given.
Six months later, KT received a reply from the doctor who was in charge of their
treatment (letter dated 16 Dec 2004) – a dispassionate response which made no
promise of changing back to Subutex. It is noteworthy that this was just two days
after Professor of Addiction Medicine Mikko Salaspuro, whom KT had
approached earlier, had sent the doctor a letter in which he informs his colleague
about a relevant piece of research and takes a stand in favour of the patients’
right to receive their former medication: “A recent study from Australia shows
that the shift from Subutex to Subuxone with similar doses does not work
smoothly and unproblematically. (...) Referring to the study above, permission to
change drugs should always be obtained from the patient. Additionally, the
patient must have the right to revert to his old medication when side-effects
occur”.11 Getting the professor on their side in this struggle was certainly a small
victory for KT. Importantly, this episode also created divisions among
substitution treatment professionals.
Patients Claim Expertise and Just Treatment
I move on now to characterise some of the most central claims made by ORT and
KT about themselves and other actors, and what they see or saw as problems that
need to be resolved with drug treatment. I do this by describing how they typify
the problem in general and what kind of examples they give of the problem, as
well as the new orientation they suggest for resolving the problems (cf. Best
1989).
Generally speaking, both groups aim to challenge and deconstruct the restrictive
social category of problem drug user. They want to break the cultural identity of
injecting drug user that no doubt is one of the most miserable and narrowest in
our societies: users are seen as marginalised and also potentially criminal,
10
11
KT, interview & petition, dated 27.4.2004.
Quotation from the letter dated 14.12.2004.
29
although these attributions increasingly display the user’s “disease of the will”
(Valverde 1998), failure of responsible self-control that they can’t help.
Both ORT and KT accept the disease concept of addiction, in fact it is the very
starting-point for their self-definition as patients. Since they are patients, they
should have the same kind of rights as any other patient group (the act on
patients’ rights is repeatedly referred to) and they should not be treated
differently from other patient groups. The core message is that disease, as a
medical problem, is something for which individuals should not be held
responsible, but also that despite their disease of addiction they are normal and
reliable patients – but now they lack the rights of patients and thus of citizens
more generally.
In their petitions and other material, both groups offer illustrative accounts of
punishments, humiliations and overly strict rules at clinics. These are presented
to exemplify the more general culture of control that pervades practices in
treatment, which again conflicts with the medical perspective. The stories draw
attention to the use of unskilled staff, attitude problems, an unprepared system,
and also the general atmosphere of repression in drug policy. For instance:
Every morning, pills are distributed in a very unpleasant and disgusting way.
Instead of natural conversation, the patient is stared at for 15–20 minutes while
the Subutex pills melt under the tongue. After this his mouth is checked to make
sure that no unmelted pills remain. (ORT, 17 Dec 98)
Therefore, the
negative attitudes of treatment personnel must be changed … The behaviour
towards addicts and their relatives must be humane and show respect … As it is,
it is best described as belittling, sometimes derogatory. (ORT, 3 Oct 97)
It is also emphasised by the groups that patients are individuals who are at
different stages of the disease and therefore they should be treated individually:
Patients are individuals, they have different histories of drug use and different
life situations. (ORT, 3 Oct 97)
Furthermore, not only are they unique individuals, but they are also experts on
their disease and life around drug use. This is a world to which no outsider has
access. The claim on expertise shows up in demands according to which patients
should have a say in deciding on the treatment and medication that suits them
best: after all it is the patient who will feel the effects or non-effects of the drug.
In addition, they also claim that they have other related expertise (from “the
streets”), as in the following excerpt:
The medical director … argued … that the health risks and street dealing of
Subutex make Subuxone a better choice. This information is incorrect: once
Subuxone treatments were started, it was immediately dealt in the streets, and in
30
contrast to what is claimed, it can be and is used intravenously. (KT, 27 April
2004)
In sum, ORT and KT present themselves as patients suffering from the disease of
addiction, which should be treated medically. The problem is that currently this
is not the case: the system is presented as an ill-prepared and unskilled
machinery of control that fails to respect their patients’ rights. Accordingly, the
groups demand that they be treated both as individuals and as experts of their
disease and life around it.
The solution proposed by ORT and KT can partly be placed under the general
heading of evidence-based medicine. Moreover, the specific treatment practices
are to be imported, particularly from France in the case of ORT. If this were to
happen, patients would receive proper treatment for their disease and they could
lead a useful life:
In the so-called French system … the patient can lead a normal social life: travel,
work, get an education … the patient can feel that the main thing is living a life
and substitution treatment is a minor point . (ORT, 17 Dec 98)
Thus ideally, being a patient would be a secondary status for them, whereas in
the current repressive treatment practice they are primarily and inescapably
reduced to the social status of drug abusers with a fatally troubled personal life
that needs to be continuously controlled from the outside.
But as the patients claim that their own expertise should be taken into account,
there is a strong element of ambivalence related to the relationship between
medical expertise and the users’ own life-world expertise. This is especially
visible when it comes to the debate on preferred treatment: although there has
been increased support in the medical camp for substitution treatment, there is an
obvious tension between the medical profession and patients about the dividing
line between the right to get treatment versus the right to get preferred treatment.
For instance, the following statement (from a newspaper interview, HS 4 Oct
1999) by a doctor from a substitution treatment clinic goes to show how
scientific and life-world expertise do not necessarily meet each other:
I don’t know whether the number [of patients who are given substitution
treatment] should be the same as the number of patients who want it. After the
expansion it will, however, meet the medical need.
The juxtaposition of medical and life-world expertise raises many sociologically
interesting questions, such as: Who claims the right to correct knowledge? What
is the relationship between scientific and professional knowledge and “lived” lay
knowledge about the effects of the same drug (buprenorphine)? The gap between
these two epistemic positions has been a central theme in medical sociology
since Talcott Parsons (1951) created his classic concept of sick role, and it has
become ever more topical; this due to two trends that have amplified the clients’
31
or patients’ voice in Western social and health care settings. The first of these is
the trend towards greater consumerism, which is particularly clear in the health
care context where patient activism has burgeoned since the 1970s (Halpern
2004). With the growing number of technologies used in health care, rising
educational level in patients, the increasing availability of health and drug
information and with patients actively seeking for information from different
sources, people have increasingly come to feel that they should have more
control over decisions affecting their bodies and be able to challenge the
physician’s authority and modes of practice (cf. Toiviainen et al. 2005). The
second trend is the growing discourse on empowering clients through
partnerships between them and the professionals, the desired end-result being
active, self-governing and self-observing clients (cf. Asmussen 2003).
In today’s reality of drug treatment in Finland, however, it is definitely too early
to speak about consumerism or empowerment. Treatments for opiate users still
seem to involve a strong element of control and the users’ rights to influence
treatment basically means the right to refuse treatment. The situation is also
complicated by the fact that the drug in question – buprenorphine – is a synthetic
opiate that can potentially be abused. In other words, the reluctance on the part
of the doctors to accept shared decision-making in the case of substitution
treatment is not only a question of patients’ rights, but it may also have to do
with moral judgements concerning intoxication.
Epilogue: The Future of Drug User Groups?
The two user groups introduced in this article are still rather weak examples of
drug user activism. In contrast to the situation in Denmark and the Netherlands,
Finland has not yet had any really influential drug user interest groups. Why is
this? Are drug users in Finland – of whom 16,000–21,000 are classified as
“problem users” (Virtanen 2005) – too oppressed or too satisfied to mobilise
themselves collectively in defence of their rights as users, clients, patients and
citizens?
Like all social movements, drug user movements are conditioned by national and
local factors: by the political norms and culture on a general level, and by the
local drug situation and its history more specifically. To answer the question as
to why user activism has remained so modest in Finland, we need to think of
these preconditions. To put this in more conceptual terms, we need to ask what
are the necessary prerequisites for such activism in society more generally; what
kind of space for action in society in general and in the drug policy field in
particular is needed for stronger drug user lobby groups not only to emerge but
to be taken seriously by other actors in the field?
32
One direction where we could look for better answers is the short history of the
current drug situation. As institutional mobilisation and creation of critical mass
take time, one candidate for a general answer to the why-not-user-activism
question is that the current drug situation, with increased levels of use and
related harms, is still new to Finnish society. As described at the beginning of
the article, it is only recently that the “first round” of institutional mobilisation
and adjustments in drug policy has been accomplished. Presumably we might
expect to see an expansion of the policy field, including more contentious users’
voices, in a second round of policy-making (a prerequisite for such a second
round is that drug use remains at the same level or increases).
Another, somewhat more specific explanation for the lack of user participation
also relates to the short Finnish history of mass drug use. On average drug users
in Finland are relatively young compared to many other European countries: in
2002 the mean age of all drug-related clients in outpatient treatment centres 12 in
Finland was 25.1 years, whereas in Denmark it was 31.6 years and both in
Sweden and in the Netherlands it was 33 years. Presumably, in order to become
politically conscious and active, users need to reach a certain age and/or have a
long enough “drug user career”, and it also takes time to form the necessary
critical mass. So perhaps in Finland user activism will rise somewhat later than
in the other Nordic countries?
We should also look at the dynamics of the drug policy field per se: to what
extent can the modest level of user activism be explained by the field of Finnish
drug policy and its established actors? In the social movement literature, the
political opportunity structure refers to the “dimensions of the political
environment which either encourage or discourage people from using collective
action” (Tarrow 1994, 18). Political opportunities are composed of several
factors, key among which is the division among policy-making elites. In the case
of substitution treatment policy in Finland, there were initially some significant
divisions among treatment experts, officials and researchers, but these divisions
soon faded and the medical lobby for substitution treatment, drawing on
“evidence-based medicine”, came out on top of the battle. What is relevant, from
the user influence point of view, is that the professional/medical lobby was
strong enough to make the change on its own; the users weren’t their allies, at
least publicly. Given the “narcophobic” cultural climate in Finland (Partanen
2002), an alliance between the medical lobby and user-patient groups could in
fact have hampered the advocacy of substitution treatment in the late 1990s.
However, once substitution treatment has reached an established position in the
drug policy field, user interest groups focusing on patient rights could be
growing in importance and establish a position in the field. Finnish treatment
experts (see Halonen 2004; Holopainen 2004) have already hoped for an
12
The number of clients in outpatient care is the only context where somewhat comparable
data from different EU-countries is available.
33
evolution of drug patient unions. Opiate users in substitution treatment may
slowly be winning recognition as “normal” patients alongside other patient
groups.
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35
Active Drug Users
– Struggling for Rights and Recognition13
Jørgen Anker
Introduction
This article investigates the processes through which a group of drug users 14 seek
to gain recognition and legitimacy as an interest organisation in The Danish
Drug User’s Union (DDUU) (BrugerForeningen for aktive stofbrugere). The
case of the Danish Drug User’s Union is particularly interesting because the
organisation seeks to organise and represent a group of citizens that are normally
excluded from channels of participation and interest mediation.15
From a broader perspective the attempt to form an interest organisation of drug
users is interesting because it may form part of a process whereby different
excluded groups and social clients attempt to gain rights to participation and
voice in the welfare state. What is of particular interest here is how the DDUU
attempts to change their stigmatised position as drug users into a position, where
they are recognised as a legitimate collective actor/interest organisation.
The article describes the position, aims and strategies of the DDUU. It explores
how the DDUU seeks to advance an alternative image of drug users as able,
respectable and active, thereby opposing the dominant image of drug addicts as
irrational, passive and irresponsible. The article also provides an insight into the
strategic dilemmas of the DDUU. On the one hand the organisation receives
public funding and seeks to use formal channels of interest representation, on the
other hand the organisation struggles for an alternative drug policy, which
challenges the official drug policies in Denmark.
Three questions will guide the discussion: First, the article seeks to explain why
and how an organisation of drug users is enabled to emerge, in spite of the strong
13
14
15
36
I thank Niels Christian Juhl Elsborg and Siri Seidelin who have been attached to the
project as research assistants. I am also grateful to Vibeke Asmussen and Jørgen Jepsen
who commented earlier drafts of this article.
When I refer to drug users in this article, I basically refer to opiate users. Activists and
members of the DDUU are primarily using heroine and methadone, but they may also
have a supplementary use of e.g. cocaine, cannabis, alcohol and benzodiazepines.
This study forms part of a research project which discusses the possible formation of
welfare movements among homeless and drug users in Denmark. The research project is
supported by the Danish Social Science Research Council.
stigmatisation of drug users in society. Second, the article will dwell with the
question of how the drug users attempt to overcome stigmatisation. Third, the
article offers an account of the impact of the organisation.
Empirically, the analysis is based on 7 tape-recorded qualitative interviews with
activists in the DDUU, and 2 tape-recorded interviews with the Parent
Organisation that is located in the offices of the DDUU. The analysis is further
informed by observation and informal conversations with activists or users in the
DDUU during opening hours or in late afternoons, participation in celebrations
of the anniversary of the organisation and other acts or meetings arranged by the
organisation.16 Documents from the organisation (the president’s annual reports,
internal minutes – so called duty reports – of daily activities etc.) have also been
analysed. To supplement these data, other actors in the field that know or
interact with the organisation have in interviews and conversations been asked
for views and interpretations concerning the organisation. These interviews
cover: 6 participants in other drug user organisations in Denmark,17 4
participants of associations of users of drop-in centres, 3 participants in
associations of ex-users, and approximately 10 actors with a professional
position in the drug field. Finally, the study also includes analysis of 116
newspaper articles that deal with the organisation.
Social movement theory is used as the principal theoretical framework to
examine the emergence and the importance of the organisation. The DDUU in
itself is an interest organisation in the drug field. Yet it may be compared to a
social movement organisation (Zald & McCarthy 1987), because it is one of a
number of associations, networks and actors that form part of broader transnational network which seeks to favour harm reduction initiatives (and seeking a
liberation of drug control policies) globally. In this sense the DDUU, as a single
organisation, may be seen as forming part of a broader social movement.
Drugs, Control and Stigmatisation
The use of drugs is condemned and rejected in most of the world. It is perceived
as harmful, dangerous and leading people into unwanted destructive life-styles,
perhaps because the use of drugs challenges the rational of the ascetic, hard
16
17
The organisation has been visited approximately 20 times, with visits lasting from one to
five hours. After these visits, notes were carried out, which have formed part of the
empirical material for the analysis.
In Århus, interviews were done with activists in Stris (Drug users’ rights in society)
[Stofbrugeres rettigheder i samfundet]. Like the DDUU, Stris was formed in 1993 but
the organisation never reached the same degree of continuity and stability. In Herning,
one interview was conducted with the president of the local user association, which also
functions as an open drop-in centre.
37
working and self-controlled modern subject. Becker (1966) describes the
situation of drug users in this way:
The drug addict, popularly considered to be a weak-willed individual who
cannot forego the indecent pleasures afforded him by opiates, is treated
repressively. He is forbidden to use drugs. Since he cannot get drugs legally, he
must get them illegally. This forces the market underground and pushes the price
of drugs up far beyond the current legitimate market price into a bracket that few
can afford on an ordinary salary. Hence the treatment of the addict’s deviance
places him in a position where it will probably be necessary to resort to deceit
and crime in order to support his habit. The behaviour is a consequence of the
public reaction to the deviance rather than a consequence of the inherent
qualities of the deviant act. (Becker 1966, 35)
Drug users are often thought of as incapable of being involved in normal life
activities such as holding a job, maintaining a place to live and fulfilling the role
as a parent (Bluthenthal 1998). Moreover, drug users experience stigmatisation
and are also often treated by state officials (police, health workers or personnel
in the judiciary) as undeserving criminals (Valiente 2003). When new houses for
homeless or drug users are planned, protests often arise from neighbours. A
national survey on relations of solidarity in Denmark thus showed that almost 20
percent of the population would involve in protest and 10 percent would possibly
move to another place if a publicly supported community of drug users was
established next door (Juul 2002).
The experience of stigmatisation is known by the participants in DDUU. One of
the activists explains:
This is the lowest [position], you can’t get any lower in this country than a drug
addict. I mean it’s much easier to come from Pakistan, to be black or woman or
to belong to any other repressed group. But a drug addict, that is the worst… and
moreover it is a dog’s life because you have to find money for drugs.18
In the interviews and conversations with activists from the DDUU and other
drug users’ organisations, it is repeated that people who use drugs generally have
miserable living conditions. The interviewees emphasise the very negative
consequences of drug use and how these influence the overall life conditions of
drug users. People who use drugs constantly have to consider how to get money
for obtaining drugs, and some have to involve in criminal activities or
prostitution. Moreover, once known as a drug user by the police repeated
controls and searches come to form part of a very stressful life (Frantzen 2005).
Attempts to organise drug users have to be understood in this light.
Compared to the other Nordic countries, Denmark has traditionally been
represented as a country with a rather liberal drug policy where harm reduction
aims have played an important role in determining concrete policies and
measures since the beginning of the 1990s (Laursen 1996; Laursen & Jepsen
18
38
Quotes of interviewees were translated into English by the author.
2002). Harm reduction can be defined as initiatives that aim at reducing the
harmful consequences of the use of drugs or improve the (often horrible) life
conditions of drug users without punishing the user for illicit drug use
(Bluthenthal 1998; Asmussen & Jöhncke 2004). Concrete examples are syringe
exchange programs, low threshold activities, outreach work and consumption
rooms (consumption rooms are not allowed in Denmark, however). Denmark
introduced many of these harm reduction measures earlier than Norway and
Finland and to a wider extent than in Sweden (e.g. free access to needles and
methadone treatment). Denmark has also traditionally maintained a more liberal
attitude towards hashish and alcohol.
However, while harm reduction initiatives on the one hand have gained wider
acceptance in policy formulations and in practice (as seen in outreach work for
example, see Asmussen 2003), control measures have been tightened up
simultaneously. As Laursen (1996) argues, it appears that a rather pragmatic and
problem-solving Danish approach to criminal justice policy has given space to a
combination of both liberal and conservative measures. Harm reduction
initiatives are thus an integrated and accepted part of the official policy as long
as they are not contradicting the overall aim of bringing the use of illicit drugs to
an end. The abstinence oriented policy is emphasised in many policy papers, but
it is also mentioned that to some of the most affected groups of drug users, harm
reduction measures are more important because abstinence in practice remains
unrealistic (Sundhedsstyrelsen 2004).
Defining the kind of initiatives that are acceptable under the heading of harm
reduction constitutes one of the ongoing struggles between supporters of harm
reduction initiatives and more sceptical actors. The Danish liberal-conservative
government has emphasised the need to define some clear lines between
acceptable and non-acceptable measures. In October 2003, the government
published an action plan against drug abuse. The title of the plan – “The fight
against drugs” – signalled a turn towards a more repressive and less liberal drug
policy. The war/struggle rhetoric framed the problem of drugs in time-typical
and well-known geopolitical terms, signalling an intention of adopting a zerotolerance policy on drugs.19 In the action plan, the government emphasises the
need to adopt hard measures on drug related crime, giving priority to law
enforcement over harm reduction measures, although still involving treatment,
prevention and harm reduction (Regeringen 2003). Penal policy and drug policy
has been tightened up: This has resulted in increased levels of punishment,
allocation of more resources to the police, construction of new prisons, prison
departments for special groups etc. A more restrictive policy on drugs has also
been effectuated through a more restrict approach to cannabis use. Possession of
drugs – particularly cannabis – for one’s own use has traditionally not been
fined, but only a warning from the police has been handed out. According to bill
19
Jepsen (2004b) describes this in a blueprint for a Danish version of the War on drugs.
39
no. 175, however, the first time reaction is now a fine, and repeated offences will
give harder penalties (higher fines or prison) (Jepsen 2004b). Moreover, the
government rejects the idea of allowing consumption rooms or to allow
treatment with heroine.
The Social Democrats (which are currently in opposition) have supported the
tightening up of penal policy and the attempts to adopt harder measures on drug
related crime. On the other hand, the entire opposition to the liberal-conservative
government except the right wing party Danish People’s Party (Dansk
Folkeparti) supports further harm reduction measures. In 2003 and 2005 the
opposition proposed to legalise consumption rooms in Denmark, but the
proposal was turned down by the government and Danish People’s Party.
The Danish Drug User’s Union
The DDUU was formed in November 1993, when a popular public activity
centre for drug and methadone users was closed down. Some of the users agreed
to form a drug users union in cooperation with some supporters (social workers
and a group of drug user’s relatives). In Denmark there are only a few
organisations of drug users, and most of these have only a few (5–10) active
participants. The DDUU, which is based in Copenhagen is the biggest and the
most important of the drug user organisations in Denmark. It has 160 paying
members and 387 passive members who have not paid their membership fee this
year (Hansen, Malmgren et al. 2005).
The character and the appearance of the physical facilities of the DDUU are
rather remarkable. There is plenty of space, rooms are well-equipped, cosy and
very clean, always ready to receive visitors and guests. The DDUU describes the
facilities with these words on its own homepage:
700 square metres headquarter in a citizen house in central Copenhagen. Here
the Drop-in Centre’s cosy café is open daily from 10 AM to 15 PM. After this
hour all activities continues but now only for active members, who’s got a fitness
room, gaming room, healthcare room, Internet and computer learning centre,
bicycle service, hobby workshop, large specialized narco related library, study
room, 70 persons lecturing room with an overhead and a large video screen, as
well as several high tech equipped administrative offices.
The DDUU is a formal organisation with an elected chairperson, an elected
executive committee, annual general meetings, by-laws etc. (Asmussen 2003).
The overall aim of the organisation is to represent and further the interests of
drug and methadone users.20 Moreover the organisation opposes discrimination
and it seeks to remedy powerlessness. It runs activities of support, information
20
40
The following description is based on the rules of the association, signed by the
chairman 18 September 2004.
and advice. It works for exposing the social, political and economic conditions in
the drug field and to uncover how these conditions affect the individual drug
user. It wants to generate debate, and it is stipulated that the organisation is
wholly committed to follow democratic means and practices to serve its
interests. Finally, it is explicitly written that the organisation must be reliable in
its relation to authorities, politicians and users.
For some of the activists, international contacts and networks are very important.
This provides them with new inputs and arguments to the debates on drug
policies in Denmark, and it serves as a form of recognition of the organisation.
The DDUU has supported the formation of a similar organisation in Norway and
Sweden and it has close contacts to user organisations in many countries around
the world. The DDUU has a number of international contacts and participates
actively in various conferences and harm reduction networks, e.g. NAMA
(National Alliance of Methadone Advocates).21 The DDUU is also a member of
ENCOD, which is a network of approximately 120 NGOs that seek to influence
and reform international drug policies seeking more transparency and democracy
in drug policy-making processes.
In practice the work of the organisation is divided into two equally important
areas. On the one hand, the organisation serves as a national interest organisation
for drug users in Denmark. On the other hand, the organisation carries out social
work and functions as a drop-in centre (an open café) that is open for all drug
users. In the morning breakfast is served and during the day there is always
coffee and tea ready for visitors. The chairman explains:
In the morning, people come in because coffee is free and a lot of other things,
of course; free newspapers, and you can sit together with equal-minded people,
and that is probably the most important reason. Here you don’t need a façade,
and as a drug user you are very conscious about that anywhere else. Wherever
you go, you know with certainty if the persons around you are aware of you
being a drug user.
With the experiences of stigmatisation and mistrust that often characterise the
efforts for and offers to drug users, the drug users in the DDUU emphasise that
the organisation and its facilities serve as a place where they can breathe freely,
without being met with suspicion and devaluation because of their drug use.22
The activists carry out social work, give advice and provide information. The
organisation runs a newspaper archive with articles on drug related issues and it
also has a library with literature on drug policies. It is mainly drug users who
seek personal advice on different issues, yet relatives to drug users also contact
21
22
The chairman of the DDUU is international director of NAMA.
The importance of meeting drug users with respect instead of control is also emphasised
as one of the important aspects of user participation in the article by Vibeke Asmussen
in this publication.
41
the organisation to get advice and information. Moreover, social workers,
students, health personnel and others often seek information at the DDUU.
In the internal duty reports it is documented that approximately 35 persons in
average visit the organisation each day (Hansen, Malmgren et al. 2005).
Approximately two thirds of the users are men, and an equal share of the users is
more than 40 years old.23 Nearly all the users (except two) started taking heroine
more than 10 years ago, and one half more than 20 years ago. The vast majority
are in some kind of maintenance treatment with either methadone or
buphrenorphine.24
The most active members stay in the organisation in the afternoon and evening.
The activists dedicate themselves to different activities that support the
organisation and they organise different recreational activities. They go on
picnics in the summer, they go biking and bowling, and they also arrange a
summer camp (team building). A group of activists celebrate Christmas Eve
together in the organisation.
The DDUU collects used syringes that have been left by drug users in the streets
in specific areas of Copenhagen. In 2004, they collected 301 kilos. 25 When
collecting used needles in the streets the activists wear yellow jackets with the
words needle-patrol written on the back. This, first of all, serves to increase the
visibility of the organisation in public. Secondly, it provides the activists that
collect needles with a certain degree of immunity vis a vis the police.
The Emergence of Drug Users as Collective Actors
The question of why social movements or social movement organisations emerge
is probably one of the questions that are most frequently asked and sought
explained in social movement theory (Goodwin & Jasper 2003). To explain why
drug users began to organise as collective actors, I follow a broader line of
explanation than the traditional political process approach (e.g. Tarrow 1994;
McAdam, Zald et al. 1996), which often limit the scope of analysis to the
political field and the concept of political opportunity structure. Political
opportunity structure refers to the consistent but not necessarily permanent
elements of the political environment that provide incentives for people to
23
24
25
42
These and the following figures are taken from a questionnaire that was answered by 61
users (of a total number of 72) who were registered as visitors/users in the organisation
from May to September 2005. The questionnaire formed part of an evaluation of the
organisation, which was commissioned by the Ministry of Social Affairs and the
Municipality of Copenhagen (Hansen, Malmgren et al. 2005).
10 of the 60 persons who answered the question do not form part of a maintenance
treatment programme.
According to the DDUU this equals nearly 20,000 used syringes.
undertake collective action affecting their expectations for success or failure
(Kitschelt 1986; Tarrow 1994).
Certain aspects of the DDUU’s action repertoire as an interest organisation are
political in character. Due to the Government’s and the opposition’s different
views on specific measures of harm reduction initiatives, the DDUU for example
has an opportunity to seek alliance partners to forward its views and arguments
in relation to concrete initiatives (for example in relation to a parliamentary
debate on consumption rooms). The DDUU thus occasionally co-operates with
some of the political parties of the opposition or other alliance partners to
generate debate and advance its views. Being aware of the existence of potential
political allies in the Parliament, who sympathise with the aims of the DDUU,
the members will find it easier to expect that the organisation is able to make a
difference. Some political dimensions (e.g. the government’s formulation of a
drug policy and the existence of allies in the drug field) are thus important to
understand the emergence, the consolidation and importance of drug users’
organisations in Denmark. But the political approach is generally better suited to
explain the emergence of collective actors that engage in political conflict.
The emergence of the DDUU, however, is not to be considered an expression of
genuine political protest. Moreover, the aims and efforts of the organisation are
directed towards both political aims (influencing drug policies) and social aims
(different kinds of self-help activities and initiatives to help and support
individual drug users). In addition, the traditional political approach often
focuses on actors that are already united by some kind of pre-existing network or
interest organisation (Melucci 1996; Crossley 2002). It is therefore less useful
when trying to explain how networks and unity is created.
For this purpose, Melucci (1996) provides a more valuable argument first and
foremost because he insists that social movements (and social movement
organisations in this case) are to be treated and analysed as social processes.
Instead of taking a movement as the starting point, analysts should try to explain
how the entity comes into being. One has to explain how the participants are
united, and what kind of relations create the foundation for any kind of collective
unity.
So, how can the emergence of the DDUU be explained? I see the following
dimensions as facilitating the process:
First, the emergence of the DDUU and other user organisations in the field are
an outcome of the ways drug users are treated and dealt with in the treatment
system.26 This argument relies on the formulations and studies of Järvinen and
26
With the treatment system, I refer to the different institutions, treatment centres, doctors,
social workers, nurses and other actors who take part in providing services, treatment or
help to people who use drugs.
43
Mik-Meyer (2003) and Gubrium and Holstein (2001), who have focused on the
relations between welfare institutions and social clients and how identities of
clients to a certain extent are formulated and formed by the features and
rationality of the institutions. The welfare institutions – physical spaces with
their own rules, rationality and power relations – come to form an important role
in the lives and identities of their clients. The point is that problem-identities of
homeless, drug users, alcoholics, or unemployed people are formed and
influenced by the institutions that are set up to help them. I do not question the
influence of the welfare institutions on the lives of social clients, yet I will argue
that welfare institutions may also provide spaces for alternative attempts to form
more autonomous actors. Thus, even if welfare institutions may be said to
partially create ‘problem identities’, these categories and identities may
eventually also come to form the basis of resistance and collective action.
My argument is that the drug users’ organisations did not emerge as an
autonomous network of drug users who decided to organise independently of the
treatment system. The conditions of drug users are often too extreme and many
drug users struggle individually to survive and get hold of drugs. These life
conditions limit the possibilities of creating a shared frame of reference from
which a collective identity could be formed. Yet the treatment system, the way
the treatment system is organised and the way it unites drug users, creates spaces
from where user organisations may be formed. The two oldest user organisations
in Denmark were both formed by a group of users of particular treatment centres.
Moreover, the issues that have mobilised drug users in protest are often related
to practices at local treatment centres.
In the treatment system drug users are provided with a space where they meet,
they are treated with standardised measures and they are thereby enabled to
acknowledge that they have many things in common and may share a number of
interests. Moreover, the treatment system also opens for alternative ideas and
interpretations, which provide openess towards new forms of treatment (e.g.
under the heading of harm reduction) and new forms of user involvement.
Outreach work or low threshold offers are examples of initiatives that are aimed
at reaching drug users by new methods opening for new ideas and different
practices of social work.
Second, the acceptance of methadone maintenance treatment was also important
for the formation of drug users’ organisations. Methadone treatment enabled
certain groups of drug users to create sufficiently stable life conditions so that
they were able to engage themselves actively in the formation of organisations of
drug users. The long Danish tradition of methadone maintenance treatment –
since the 1970s in Denmark – contrasts the situation in other Nordic countries,
where maintenance treatment has been introduced later (Norway and Finland) or
has been more restricted (Sweden). Drug users in Norway, Finland and Sweden
may thus have had more difficulties reaching a sufficiently tolerable life
44
situation, which could provide them with energy to form and engage in user
organisations. This could be used as one possible explanatory factor for the later
emergence of drug users’ organisations i.e. in Norway (1996) and Sweden
(2002).
Third, harm reduction strategies in Denmark opened opportunities for drug user
organisation. Bluthenthal (1998), Friedman, Southwell et al. (2001) and Wieloch
(2002) associate the appearance of harm reduction measures with the emergence
of a harm reduction movement. The harm reduction philosophies and the harm
reduction movement simply created a space for the acceptance and recognition
of drug users’ organisations. Harm reduction arguments provided drug users’
organisations with an important basis from which, arguments and critique could
be raised. Harm reduction approaches offer an alternative to traditional moral
approaches; 1) the war on drugs and 2) the disease model of addiction (Wieloch
2002, 47–48). Claiming that initiatives have to support drug users instead of
punishing or controlling them form a part of a larger cultural field or meaning
system (Wieloch 2002). Relying on this meaning system facilitates drug user’s
organisations’ opportunities to gain recognition and frame their claims.
Fourth, the existence of a favourable environment, with a number of supporting
actors may also help explain the emergence of drug user organisations in
Denmark. A good example is a Parents’ organisation (“Parents Association to
drugs-influenced children”; Forældreforeningen til Narkoramte børn) that was
formed in 1974. This organisation had the explicit aim of seeking to obtain a
general acceptance and use of methadone maintenance treatment in Denmark. In
practice, in the 1970s, before methadone was accepted as a treatment measure,
the organisation attempted to find doctors who would prescribe methadone to
drug users. A lot of the work of the president of the organisation consisted in coordinating and delivering methadone to drug users from doctors who were
willing to prescribe methadone.27 Later the participants in the organisation also
supported the formation of the DDUU.28
Finally, a general trend of user orientation in welfare policies in Denmark
created an institutional platform for user organisations. The Ministry of Social
Affairs played an important role in this process, providing support and
legitimacy for the DDUU.29 On the one hand, this orientation secured resources
and financial support, on the other hand, it opened channels for interest
27
28
29
Interview with Poul Thyge Petersen. Former president of the organisation of relatives to
drug users that supports harm reduction initiatives. There is also another organisation of
relatives to drug users in Denmark, which is much more critical of harm reduction
initiatives.
Today, the organisation is called Landsforeningen for human narkobehandling (The
national association for human drug-treatment). It works closely together with the
DDUU and its office is situated within the premises of the DDUU.
For further discussion of this, see Anker 2005.
45
representation. The interest in user participation has been institutionalised in the
social legislation (see Asmussen 2003), and the discourse which favours user
participation has opened opportunities for drug users to make claims towards the
system on behalf of their position as users. The status as users of social services
thus provides drug user organisations with a certain degree of legitimacy, when
they attempt to organise (Asmussen & Jöhncke 2004).
The Self-representation of the DDUU
The DDUU seeks to construct an image of drug users that opposes the
stereotyped image of drug addicts. This may be seen as part of a symbolic
struggle, and an attempt to redefine the meaning of ‘drug user’. In short, the
DDUU attempts to elevate a stigma to a position of status (Wieloch 2002). The
organisation struggles for giving drug users a status and a position of recognition
as decent citizens and it claims a right for the drug users to be treated with
respect and to be heard when drug policy issues are discussed.
The DDUU seeks to advance a positive image of itself in the public towards the
exterior. But the self-representation also forms part of a collective identity, a
collective understanding of how ‘we’ – the group of activist and members/users
of the organisation – are. This self-understanding is influenced by the ways drug
users are characterised and dealt with by the welfare- and treatment institutions,
the media, politicians and the public in general.
In its attempts to construct a specific image of itself the DDUU emphasises the
word ‘active’, which is given a double meaning. On the one hand, it means that
the users and activists of the DDUU have an active use of drugs, on the other it
means that the users and activists are ‘actively’ involved in different activities.
The very existence of the DDUU and the fact that the DDUU is driven
effectively and autonomously by active drug users themselves is emphasised as a
living proof of drug users’ capabilities.
Active Drug Users
The name of the organisation is in itself a symbolic challenge to public
stereotypes. In Danish the formal name of the organisation is the Users’ Union
for active drugs users – BrugerForeningen for aktive stofbrugere. The chairman
explains:
They wouldn’t call it the drug misuser’s association or the association of drug
addiction, but the users’ union.
46
But we agreed that the starting point is active users of drugs and we work for the
active drug users. We don’t declare ourselves drug addicts. We make the
distinction that if you pay your rent each month and take care of yourself, then
you are a consumer, no matter how you use your money. And we, then, are
consumers of drugs, but we also have a lot of activities, so it has double
connotations: The union is for active drug users that take drugs, but also want to
be actively involved in different activities.
The organisation thus seeks to detach itself and its members from the
denomination drug addicts or drug misusers, claiming that they rather be
considered as consumers. Whereas drug addicts or drug misusers are persons
that are so troubled that they need help and support, consumers are persons who
have their own resources and follow their own interests. Moreover consumers
have rights and ultimately they also have a right to use the kind of drugs they
want and physically need.
Indicating that the organisation represents a group of people who have an
’active’ use of drugs (primarily heroine and methadone) in itself represents a
symbolic challenge in a society where illegal use of these drugs is prosecuted.
Additionally the name indicates a difference to groups of ex-users who organise
in different groups of Narcotics Anonymous. Initially, the members of DDUU
were afraid that ex-users should become too dominant in the organisation, so in
the by-laws, it is stipulated that only active users of drugs can become board
members. Yet ex-users are still welcome in the organisation and a former
president who is no longer an active drug user is occasionally invited as a
speaker to public meetings or celebrations.
But ex-users often tend to take on a very moralising attitude towards drug users,
activists in the DDUU explain. This means that some ex-users can have
difficulties accepting that others continue with their drug use, whereas they have
themselves managed to stop. The DDUU does not condemn ex-users and the
people who manage to quit, but the organisation claims a right to continue with
drug use without being condemned by others.
Active Participation
The meaning of active also in many ways constitutes the boundaries used to
distinguish members and activists of the DDUU from other organisations and
drop-in centres in the field. It dissociates the organisation from places and drug
users that are not formed around an intention to involve in collective activities.
The organisation is described as a place of activity. This means that the people
who show up regularly are expected to participate actively in the different daily
tasks. It is not well-seen, and it is commented upon, if people do not participate
in any activities. Active in this sense thus signals that drug users are not just
47
passive social clients but rather active and engaged subjects. The DDUU seeks to
emphasise this through involvement in different events, teaching activities etc.
In practice the meaning of active, also serves as a differential mechanism, which
defines who are included in the group and who are not. Being active means being
involved in activities for the good of the organisation. The degree of activism
forms one of the mechanisms of internal differentiation. Only a smaller group of
people – an ‘inner core’ – holds the formal title of ‘activist’ (approx. 15–20
members). Activists take ‘duties.’ This means that they are responsible for the
activities that take place in the organisation on the day of their duty. They have
to make breakfast, answer the telephone during the day, say hello to visitors and
a number of other practical tasks. Being an activist is a formal status that
provides the person with a key to the organisation, and activists can thus come
and go as they like. To become an activist, one has to follow one of the persons
on duty for a longer period of time. Only after having participated actively in
15–20 or more duties, it is decided if people are trustworthy to be given a key to
the organisation. The key represents the ultimate symbol of trust. It serves as a
sign of recognition and belonging. The chairman of the DDUU explains:
Well, we don’t make contracts with people… and anyway it wouldn’t help… [.. ]
so if we give a key to the wrong person, and this person empties the place for all
values, then we can’t do anything…. [….] .. but we choose to be a little more
strict on this issue and have the rule that the keys are something that people must
qualify for. It is the ultimate sign of honour you can receive… so to say.
As explained above this rather formal selection procedure of activists is meant to
protect the organisation from unintended loss. The organisation has experienced
various examples of theft and loss. To prevent theft, all offices are locked and
have to be opened with a key, if there is no one present in the office.
Gaining the recognition as an activist with a key thus provides an improved
position in the internal hierarchy of the organisation and it also gives certain
privileges (contribution to the payment of transport or mobile phone and
possibility to participate in the team-building tour in the summer). To become an
activist with a key, you have to show – through your continued effort for the
good of the organisation – that you deserve recognition as an activist. The most
active, the ones that work the most are also the people that decide, the ones with
status and power.
The meaning of the name of the organisation is not just used to provide an
alternative image of drug users in the public. It is also used as the logic through
which internal hierarchies are formed and boundary work is carried out. It is
used in the process of constructing a collective self (Hunt & Benford 2004).
Autonomous and Able Drug Users
48
One of the issues that activists in the DDUU repeatedly raise, when talking about
the organisation, is that it is an organisation run by and for drug users
themselves. The requirement of only letting active drug users into the board is
meant to secure that the organisation remains controlled by the activists and
members themselves. Self-determination and autonomy are very important in the
collective self-understanding of the organisation. It is not an organisation
operated or influenced by social workers – or others – who act on behalf of drug
users. This creates a feeling of autonomy, a sense of being accepted among
equals. The activists describe the organisation as a success, which is often
related to a perception of self-reliance which also forms part of the narrative of
the organisation’s history.
The history is told as a story of how the activists gradually developed a stronger
belief in their own capacities. In the beginning, it is explained, people were
clientilised,30 yet gradually – after some unpleasant incidents with non-users who
suddenly became too dominant in the organisation – the users realised that they
were able to take the responsibility and to manage by themselves. On this basis,
the activists claim a right to live an autonomous life, without interference from
people who believe that they are more capable because they do not use drugs.
Another important and related aspect in the self-understanding of the activists is
that the physical facilities always appear clean and tidy.31 Keeping rooms clean
and tidy, the DDUU seeks to gain and show an image of drug users that
contradicts the normal stereotypes of drug users as messy and unable to take care
of things. The image of a professional, well-functioning organisation with good
facilities thus becomes an ideal expression of the position aimed at. This is how
the organisation wants to be seen by others. This is the kind of recognition the
active drug users seek: Perhaps different, but still basically the same, and in any
case responsible and able.
Seeking Legitimacy
Many of the activities which are carried out by the DDUU are aimed at gaining
recognition for the union as a useful, serious and reliable organisation, which
carries out important social work to help drug users to gain a better reputation in
society or to inform about drugs and drug users’ problems in the public. As
mentioned, the needle patrol is one example of this strategy. Another example is
the attempts to carry out social work for drug users in the street. A few years
ago, the DDUU thus had a project in which they carried out outreach work in
30
31
Meaning that they felt like clients. They didn’t think they were capable of running the
organisation by themselves.
This is often mentioned in my informal conversations with the activists. It is also noted
repeatedly by visitors from abroad.
49
Vesterbro in Copenhagen where many drug users gather. The activists made an
effort to get in contact with drug users in the street and offer support, help or
treatment.
The DDUU has gained legitimacy because of its work, and this can be illustrated
by the public support for the organisation. To receive public funds is also to be
accorded legitimacy (Valiente 2003). Over the years, the DDUU has gradually
gained more public funding to a degree where the organisation today appears to
be entirely dependent on funding from the authorities. The DDUU has been able
to adjust or transform its aims and strategies to projects and activities that are
perceived as acceptable and needed by the local and national authorities. In
2003, the DDUU received a total of 1.7 million DKR. (approx. 226.700 Euro)
from the public authorities, half of this amount from the Ministry of Social
Affairs, and the other half from the Municipality of Copenhagen. In 2003, for the
first time in the history of the organisation, the DDUU was guaranteed an
appropriation for three years.
Yet, because of the illegal character of drugs, drug users’ organisations are
placed in a difficult intermediate position. The organisations admit or openly
emphasise that their members have an active use of illicit drugs, implicitly
acknowledging that they are involved in illegal acts of buying and possessing
drugs. The organisations thereby run the risk of being condemned and repudiated
by the surrounding society as illegal and illegitimate organisations. The DDUU
has faced this threat in various occasions. Confronting the risk of being denied a
right to exist, the organisation has opted for seeking legitimacy through good
behaviour.
Most harmful to the organisation are accusations of illegal drug dealing in its
rooms, brought up by the tabloid newspaper Ekstrabladet in April 2000. A
journalist had visited the organisation for a few days, and the paper claimed to
possess recordings which proved that drug dealing took place in the rooms of the
organisation.32 The story immediately raised a political debate on the conditions
of public support and if public means were used to finance drug dealing. 33 As a
result, police investigations and financial revisions were started. The DDUU
maintained that individual members who use drugs obviously sometimes buy
drugs together to get them cheaper. But even if such arrangements occasionally
take place they do not involve the organisation as such, the chairman argued in
the newspaper. Neither the police investigations nor the financial revisions of the
organisation found any proofs of illegal activities.
In 2004, the DDUU again confronted a problem due to members’ active use of
illegal drugs. The chairman was convicted to prison for nearly a year for
possession of heroine. The group of activists was stopped by the police,
32
33
50
Ekstrabladet 3 April, 2000.
Ekstrabladet 4 April, 2000.
precisely when they had taken off to go on the yearly summer vacation. The
conviction led once more to financial revisions as well as an external evaluation
of the organisation. Yet the organisation succeeded to continue its activities
while the chairman was in prison.
The DDUU maintains that the use of drugs is a private matter. The aim of the
organisation is not to form a club that provides the infra-structure for taking and
using drugs, but to be an interest organisation and a drop-in centre for drug
users. On the other hand, in some cases the activists in the organisation have to
show acts of solidarity with individual users. This has occurred on occasions,
when drug users in methadone treatment have been excluded from the treatment
programme and suddenly are standing on the street with abstinences. In such
cases, the activists have ‘passed the hat around’, trying to help in the specific
situation.34 While this practice indeed illustrates the caring and helpful
atmosphere of the DDUU, it can also give rise to myths and bad press.35
Another example of how difficult it is for an organisation of drug users to put
forward arguments that may be judged as controversial in the public was
exposed in a parliamentary debate on a proposal of introducing health or
consumption rooms in Denmark.36 In the debate Birthe Skaarup, MP, from the
right wing party Danish People’s Party (Dansk Folkeparti) argued that the idea
of health or consumption rooms was supported by a powerful drug-industry (and
maybe drug dealers) involved in lobby-activities to increase the amount of drugs
sold in Denmark. She argued that the DDUU was one of the organisations that
had positive remarks on the proposal prior to the parliamentary debate and that
the DDUU had supported an international campaign in favour of liberalising
international drug conventions.
Such attempts to de-legitimise the organisation’s raison d’être clearly illustrates
that there are limits to the kind of proposals and actions that stigmatised groups
can support or get involved in without being suspected of having criminal
intents. To protect the organisation from suspicion and critique, the organisation
seeks to provide an image of itself as a nice, clean and well-functioning
organisation with well-functioning activists. The activists do not deny that they
take drugs, but on the other hand they are very cautious not to bring forward
34
35
36
Ekstrabladet 4 April, 2000.
The newspaper articles in this study were searched on the Internet site ‘infomedia’,
which contains newspaper articles from all the newspapers in Denmark. A total of 116
articles were found which had ‘The Danish Drug Users’ Union’ included in the text. Of
these 116 articles, 10 were very critical or negative in their description of the
organisation, indicating that bad publicity is not a general trend of the media
representation. The articles found dates back to May 1996 and carry on until November
2004. It must be noted that not all Danish newspapers have been represented in the data
base in this period.
Proposition B 68 proposed 14 January 2003. The following references are from the
parliamentary debate of 28 February, 2003.
51
views that would be too controversial in relation to the current drug policy in
Denmark. The organisation has given priority to seeking legitimacy and
providing an image of drug users as basically decent and able citizens, instead of
following a more disruptive and confrontational strategy.
Balancing the Claims: Critical But Useful
Politically, the DDUU seeks to advance harm reduction initiatives in a broad
sense (including any initiative which could improve the situation of and respect
for drug users). To the DDUU the problem is not so much the drugs. The issues
of importance are the life conditions of drug users and the ways whereby drug
users are treated by society, the police and treatment institutions. The DDUU
favours health rooms or consumption rooms, where drug users can inject their
drugs under more secure conditions. It also favours treatment or maintenance
programmes with heroine. The DDUU claims that allowing these measures in
Denmark would reduce the number of drug related deaths and harms
significantly. But these proposals are only occasionally raised as clear-cut
demands in the public. Some years ago, the organisation organised a public
demonstration in favour of heroin maintenance, but it does normally not use a
strategy of protests to call attention to its claims.
The organisation rather seeks to behave as ‘good’ and responsible citizens,
adhering to a strategy where the activists show a good example (as responsible
drug users, who – for example – clean up the used syringes of other drug users).
In this way, the activists attempt to provide an alternative image of drug users in
the public, seeking to challenge stigmatisation, but also seeking to establish a
position from which they may be taken seriously by the authorities. Thus, instead
of calling attention through interrupting or challenging strategies, the
organisation seeks to gain legitimacy as a serious organisation, which can
participate in direct negotiations and dialogues with the authorities.
Even if public funding provides the organisation with official legitimacy, public
funding also works as a co-opting mechanism which tends to limit the strategies
that are available to the organisation (Jepsen 2004a). Too much critique of
national policies or specific treatment measures could have a negative impact on
the possibilities to gain resources in the future. It could also harm the image of
the organisation in the public. The chairman explains:
We have to be aware of the national conditions, and we have to adapt ourselves
to the fact that we have a weak foundation. We are not supported by the
population, we have these public funds and our subscriptions…. So we are very
conscious to move carefully on the thin ice, if we pass the line, we react
immediately and turn around. We are not going to stick our necks out, so we
don’t go out and make a lot of noise.
52
The DDUU thus seeks to establish and maintain good contacts with the different
actors in the field (social workers, civil servants in the Ministries and
municipalities, health personal, doctors, experts, and politicians). The DDUU
has in this way succeeded in forming informal alliances with many different
actors in the field, gaining influence through networks and personal contacts.
One of the ways to establish these contacts, is among other things the celebration
of the anniversary of the organisation. On this day, a user-friend’s prize is
awarded to someone who is working in the field.37 Most of the relevant actors in
the drug field show up on this day, including representatives from the Ministry
of Social Affairs.
The organisation also gives priority to carrying out information activities. The
DDUU reaches a number of different actors in this way, gaining recognition as
reliable actors, who present the views of drug users. From January 2004 to July
2005, 42 formal lectures were given for approx. 735 persons and moreover
minor groups of students and other visitors often get information in informal
conversations (Hansen, Malmgren et al. 2005). The DDUU is thus able to reach
decision-makers, administrative personal, and also front line workers (police
officers and social workers) whom the drug users often face in their interaction
with the authorities.
When the DDUU attempts to call attention to its objectives and its proposals for
alternative drug policy measures, the organisation often use symbolic acts. Each
year the organisation organises a memorial act to honour and call attention to the
users who have died from drug-related deaths during the year. This ceremony
takes place at a memorial site that was established in 2003 with support from the
municipality of Copenhagen. In 2004 one cross for each drug user that died were
placed in the memorial site. In this way the DDUU attempts to get attention from
the media and to raise debate on the consequences of a control oriented drug
policy.
But in spite of the recognition that the DDUU has gained, it remains in a difficult
position. The DDUU risks to loose funding and to damage its image as a
responsible and serious organisation if it brings forward views that are too
controversial or if it involves in activities that would be condemned by the
public. The DDUU is in other words, constrained by what can be said and done.
As argued by Meyer (2004), even if social movement organisations make
choices about how to present themselves and their claims, they do not
themselves design the circumstances (Meyer 2004, 53).
37
This is a good example of the connections between national user organisations and how
the action repertoire is copied across national frontiers. The idea appears to have
originated from user organisations in The Netherlands (see the article by Dolf Tops in
this publication). It is now also applied by other similar user organisations for example
in Sweden.
53
Achievements and Limitations
The traditional way to assess the significance of social movement organisations
is to evaluate the political influence of the organisation (Gamson 1975; Giugni,
McAdam et al. 1999). I want to claim, however, that a delimited political focus
is insufficient for understanding the importance of the DDUU. The significance
of the DDUU as an interest organisation in the field only refers to one dimension
of DDUU’s work.
First, I will argue that the existence of an organisation of drug users in itself is a
remarkable achievement that deserves recognition. The DDUU is run by people
with an active use of opiates or methadone, without interference from
professionals or non-users. Running an effective and well-functioning user
organisation38 by principle challenges the stereotyped image of drug users as
untrustworthy, self-centred addicts who are unable to be trusted with
responsibilities. In this way, the DDUU is an existing proof of the organisation’s
own claim; that an active use of opiates does not in itself lead to non-social
behaviour, and that it is possible to live a decent life as a drug user (Jepsen
2004a).
When the organisation appears in the media, it invariably provides an alternative
image of drug users. But even if most articles about the organisation are positive,
it still has limited possibilities of changing denigrating practices and stereotyped
images of drug users. Providing an alternative image is one thing, changing
practice is a completely different thing.
Through its continued efforts in the field, the DDUU has gained recognition as
an entity which should be taken seriously. The authorities recognise DDUU as a
legitimate interest organisation, and as such it is facilitated by public means. The
chairman explains how they are taken into consideration by the authorities:
Things that are related to us are circulated to us for consideration. When a new
law is being processed, we are asked and so on. I will say that being asked
provides us with a certain degree of status. Well, perhaps they do not follow our
arguments, but sometimes at least we are able to put our fingerprints on the
content.
A few years ago, the DDUU also had a seat in the Board of Narcotics, where the
chairman could participate in different working groups and bring forward the
opinions of the organisation. The board was closed down in 2002, however, and
the organisation thus lost an important platform for mediation.
38
54
Jepsen (2004a) characterises the organisation as well-functioning and this assessment is
supported by interviews with other actors in the field.
The DDUU had a saying regarding treatment with methadone. On the one hand,
the organisation influenced the formulations that became part of the revisions of
the methadone circular. On the other hand, the DDUU has also been able to call
attention to – and to achieve changes in – local practices that have been
experienced as denigrating and harmful to drug users. Thus the DDUU with
support from a lawyer opposed the practice of mixing juice and methadone. The
president explains:
They mixed juice and methadone to prevent people from injecting it. When
people injected it anyway…. it meant that they got staphylococcus in the heart
valves and things like that… We were very determined to get rid of that.
The DDUU was able to change this practice, and it has also in other occasions
been involved in attempts to question or change specific practices at the
treatment institutions.
Yet, apart from these achievements as an interest organisation, the DDUU must
also be valued for the importance it has for its members. The organisation serves
as a unifying point of a social network of drug users who often lack more stabile
life conditions and social relations. Through the work and experiences in the
DDUU, the activists gradually gain self-confidence, they gain a position, an
identity:
Well, we seek not just to de-criminalise but also to de-stigmatise [drug use]. We
think that this is important, and we experience it right here… You can look
around at the people who are here now, none of them walk around hiding
themselves. They are satisfied with being here and with the work they are doing.
They are doing something important, you see… They are not ashamed, because
they gradually have realised that we actually have something here to be pleased
with, and to be proud of. We made this project thrive.
Through the activities of the organisation, the drug users become part of a
collective, which has the organisation and its activities as their shared point of
reference. The organisation provides a space where the activists feel that they
can involve in meaningful activities.
Asked directly, if the organisation may be compared to some kind of movement,
the chairman replies that it is rather to be seen as a big family. What is entailed
in this statement is that the internal life and the close social networks between
the activists and members in many ways appear to be more important than
mobilising activists in collective action. To many of the activists, the
organisation serves as a primary social network. It is the space and context of
many of the daily activities and the place where many recreational activities take
place.
I gain from this because I’m able to get out of bed in the morning, to do
something, instead of just sitting at home without doing anything. So, I’m very
happy to come here in the association. Before I started coming, I had a
55
depression for three years, where I just took my methadone but stayed in my bed.
For almost three years. And then I started coming here..[…]… And I started to
learn to take duties and so on. And then I had something to wake up to, and I
was able to get out of that stupid bed.
The activists in the DDUU in many ways care for each other like in a family. If
people do not show up, when they are expected to, some of the activists try to
make contact to them to ensure that nothing is wrong. In my view, it is very
important to emphasise the significance of this internal solidarity. As an interest
organisation, the DDUU holds an important role because it has gained a position
from which it is able to speak up for drug users. As a self-help organisation it
serves as a unifying entity, which gives new meaning and content to the lives of
many of its members.
The primary strength of the network of activists could – from a social movement
perspective – also form a barrier to the organisation, if it ends up as a selfsufficient network that is unable to recruit new activists. This dilemma relates to
another problem that is well-known in these types of organisations, namely that
it is a relatively small number of activists which carry out most of the work
(Hansen, Malmgren et al. 2005). If the organisation is not able to recruit and
involve new members and activists, it may be difficult to continue the work with
the same kind of energy and results.
Conclusion
The DDUU reflects to a wide degree the developments and the organisation of
the treatment system. First, the treatment system provided the space that enabled
user organisations to emerge. Second, the DDUU was formed by users of a
treatment centre that was closed down, and in many ways it gains its legitimacy
from its interaction with the actors of the treatment system. Third, the
organisation serves as an alternative offer to drug users, through which people
can involve themselves in activities without interference from social workers,
health workers, etc. It is also noteworthy that the DDUU does not make a lot of
efforts to challenge penal policy. It rather focuses on seeking to expand the kind
of measures that are accepted as harm reduction initiatives (injection of
methadone, treatment with heroine, consumption rooms etc.). In this way the
work is directed towards the issues that are currently open for political debate,
and issues where differences between the political parties provide a space for
advancing the users’ view.
Stigmatisation of drug users and dependence of public means influence the
strategies of the organisation. Bad publicity that questions the activities that take
place in the organisation, illustrates how delicate the position of the organisation
is in a society that condemns the use of illicit drugs and drug users. Drug users
56
are almost automatically looked at with suspicion, and consequently an
organisation of drug users has to prove that it is trustworthy to a wider degree
than other social organisations. The DDUU has succeeded in gaining recognition
as a reliable, serious and useful organisation, and following this strategy it has
gained influence on policy documents and concrete practices in the treatment
system.
The DDUU claims rights for drug users (rights to be treated with respect). An
important part of the efforts of the DDUU is manifested in activities that are
intended to prove that drug users basically are like any other citizens. They have
skills, resources, and they are able to run an organisation effectively, just like
any other interest organisation in the welfare society. More than attempting to
challenge the system, it seeks to become part of it. Therefore, it takes on
responsibilities and carry out activities, which are recognised as important and
useful by the surrounding society. The DDUU informs about drugs, it is involved
in social work, and it collects used syringes on the streets to improve the image
and understanding of drug users and to alleviate stigmatisation.
So, the DDUU is not a radical movement in the sense that it organises a number
of protests to call attention to the drug problem or change drug policies. Instead
the organisation seeks a position from which it can get into dialogues and
negotiations with authorities. It does not exist outside the legitimate institutions,
and the success of the organisation in fact depends upon the apparatus of the
state (Wieloch 2002, 66). It tends to play down controversial aspects and in this
way gain access to the formal channels of interest mediation of the democratic
system. At the same time, the DDUU forms an autonomous space and a small
community for drug users, whom through their engagement in the collective
activities in the organisation are given status, position and identity.
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59
Stretching the Limits of Drug Policies:
An Uneasy Balancing Act
Dolf Tops
Introduction
Organisations for and by hard drug users have been a common phenomenon in
the Netherlands ever since the late 1970s. The user organisation in focus in this
article, the Amsterdam-based Interest Association for Drug Users or MDHG
was founded almost 30 years ago. Unlike most Scandinavian user organisations,
the MDHG is neither a self-help group/client organisation, nor closely related to
a treatment system or treatment issue. Instead, it proclaims to represent and
defend the interests and rights of drug users, and its main goal is a political one,
namely the legalisation of hard drugs. This makes the MDHG a particularly
interesting case from a Nordic perspective, for such an objective is taboo or
would at least not be explicitly declared by user organisations in the Nordic
countries.
My purpose in this article is to describe how the Dutch context has made
possible the emergence of a relatively autonomous group of user organisations. I
will illustrate how user organisations are influenced by general drug policy and
by the institutional structure of the political system.
Based on the principles of harm reduction, Dutch drug policy differs quite
considerably from the Swedish goals of a drug-free society and therefore
provides an interesting backdrop for an analysis of how it influences the modus
operandi and goals of user organisations. The harm reduction approach does not
focus on illegal drug use as such, but on preventing and reducing the risks of
drug use to both users themselves, the immediate environment and society.
Reducing the risks for society is the origin of the public nuisance policy that
incrementally paralleled the harm reduction approach in the Netherlands and that
is targeted at the behaviour of the drug user rather than drug taking as such. The
drug-free society approach, on the other hand, is aimed at eliminating illegal
drug use altogether, and one of the means of achieving this is by the
criminalisation of drug use. Logically, the approach determines the limits for the
organisation of users as well as for their aims, strategies, activities and action
repertoire.
Apart from drug policy, another important aspect facilitating the emergence of
user organisations is the institutional structure of the political system. In this
case, both the Nordic countries and the Netherlands can be characterised as
60
cooperative states with long traditions of involving civic organisations in the
policy-making process.
A third relevant factor concerns the constituency of drug user organisations.
Although drug use does not necessarily and automatically imply individual or
social problems, the constituency of organisations for and by hard drug users
usually consist of marginalised people with multiple problems, including drug
use, homelessness, psychiatric disorders, etc. This presents a special challenge to
these organisations in terms of encouraging users to get involved and to sustain
that involvement.
In this article I will be describing the ways in which the MDHG is working to
stretch the limits and possibilities imposed by society by focusing on its
organisational form, the issues that are raised, its action repertoire and aims in
relation to the local context.
Social Movement Organisations and Their Context
Structure
The MDHG may be described as a social movement organisation, i.e. an
organisation that pursues a political goal by means of collective action. My
choice to call it a social movement organisation instead of a social movement is
deliberate. According to Tilly (2004, 4), one of the characteristics of social
movements in the West is that participants concert public representations of
WUNC: worthiness, unity, numbers and commitment on the part of themselves
and/or their constituencies. In this sense, the MDHG is not a social movement
because even though it promotes the W and the C certainly is present, user
organisations do not display numbers (they do not march in ranks) and there are
also questions about unity. However, if we regard the emergence of user
organisations in Western Europe as a social movement, local organisations are
part of this phenomenon and thus social movement organisations. This argument
is strengthened by the fact that there exist international networks of user
organisations where information about local developments is exchanged and
where the action repertoire is emulated. User organisations also support
initiatives to set up new organisations where such do not exist.
One way of analysing social movement organisations is via the concept of
context structure (Rucht 1996). In this concept, conditions external to a
movement (or set of movements) either restrict or facilitate the building and
maintenance of a movement structure devoted to conducting protest activities
(ibid., 189). The most crucial contextual dimensions are the cultural, social, and
political contexts:
61
•
The cultural context refers to the attitudes and behaviours of individuals
who may (or may not) provide support such as money, organisational
help, or personal involvement in protest events. This depends on how a
movement’s issue and demands resonate with the experiences and
interests of larger sections of the population. This resonance is a
function of the distribution of cultural patterns among certain groups in
the population and the framing of the problems at stake. Here both
general values and more situationally dependent issue perceptions come
into play.
•
The social context is the embedding of social movements in their social
environment. One aspect consists of the social milieus and networks,
which either facilitate or restrict the forming of collective identity and
the building of movement structures. For example, population density
facilitates communication and mobility between networks.
•
The political context is where conceptions of political opportunity
structures are focused, singling out factors such as access to the polity,
political alignments, presence or absence of allies, and conflict among
the elites (ibid., 190).
In this article I use the concept of context structure to describe the MDHG and
its operation. The focus is on what McCarthy (1996, 142), referring to Tilly
(1985), described as a key task in the study of mobilising structures, namely to
characterise “the social movement” by its typical social location and associated
strategic and tactical approaches. In effectively choosing mobilising structures,
activists must successfully frame them as usable and appropriate to the tasks of
social change they employ. The targets of these framings are both internal –
adherents and activists of the movement itself – as well as external, including
bystanders, opponents, and authorities. This means that the framing of action is
intimately related to the cultural context in which a social movement builds its
mobilisation structure (ibid., 149).
The empirical data for the article consist of interviews in April 2005 with three
persons working in user organisations and one official from the Department of
Social Affairs. The magazine “Spuit 11”, published by the MDHG since 1981,
and the organisation’s annual reports have also provided important sources of
information. Additional material has been collected through the Internet.
In the following the main focus is on significant aspects and changes in the
Dutch context that have contributed to the emergence of the MDHG and some
other user organisations.
62
From Drug Free to Harm Reduction
One important contextual factor is of course the national drug policy and its
impact on possibilities for drug user organisation. Dutch drug policy is
characterised by a two-track approach, with separate policies on cannabis
products and so-called hard drugs. This principle, as set out in the Opium Act of
1976, has been at the centre of Dutch drug policy ever since. The focus here is
on the policy on hard drugs, i.e. heroin and cocaine, for it is precisely these users
who are targeted by user organisations in the Netherlands.
Heroin appeared on the Dutch illegal drug market in 1972, presenting the
authorities and treatment organisations with a whole new problem. Based on
experiences and research from abroad, especially the United States, there were
fears of a heroin epidemic, particularly among socially marginalised sections of
the young population. These fears materialised sooner than anyone had expected
and in 1976, the number of people addicted to heroin in Amsterdam was
estimated at 5,000–7,000 (Tops 2001, 123). The number of problem users
peaked at 8,800 in 1988, and has declined until 1998.39 This decline has been
explained by the return of German and Italian users to their home countries. The
number of problem users of opiates (most of whom also used cocaine) in 2003
was estimated at 4,530. The use of cocaine (coke base) seems to be primarily a
big city phenomenon and common among homeless people (Trimbos 2005).
A major shift occurred in national drug policy in the early 1980s. The
philosophy and goals of the traditional treatment system were increasingly called
into question (not least because of its poor results) by user organisations, left
wing parties and progressive treatment professionals. Eventually, the system
bowed to the pressure. Instead of taking abstinence as the only goal for
treatment, politicians began to accept more differentiated goals. Coming off
drugs, for those who were able to, and a policy of “harm reduction” for those
who were not (yet) able to quit drugs, were adopted as the leading principle for
care and treatment institutions. It was considered a kind of social contract where
society, on the one hand provided assistance that enabled drug users to reduce
the risks of drug use, for example by low-threshold assistance facilities, and drug
users on the other hand would and could behave as common citizens (whatever
that might be). This policy became denoted as the normalisation of the drug user
and entailed a further categorisation of drug users into socially normalised and
integrated users, on the one hand, and those who could not or did not want be
normalised, on the other, eventually becoming problem users or extreme problem
users.40 The latter two categories became the constituency of the MDGH. When
compared internationally, the adoption of what later became known as the policy
39
The number of problematic drug users in the Netherlands was estimated at 32,000
(2001) which compared to most other EU countries is quite low (Trimbos 2004). The
number of drug addicts per 1,000 population in the Netherlands was 3.0, in Denmark
7.2, Sweden 4.5, Finland 3.5 and Norway 4.2 (EMCDDA 2005).
63
of harm reduction, in which the aim was to reduce the risks of drug use to the
user and society instead of curing all drug users, took place at a rather early
stage.41 One of the consequences was particularly visible: thousands of addicts
from abroad (many from Germany) sought and found refuge in Amsterdam.
Another part of the social context concerns the period in which drug user
organisations emerged. User organisations were one among numerous action
groups that emerged in the 1960s and later. In many fields of social life, groups
of people felt oppressed and claimed the same human rights as other citizens. To
name just some, homosexuals, psychiatric patients and women’s liberation
movements called for equal rights, squatters for housing, and students for the
democratisation of universities. In this pandemonium of protests, drug user
organisations were just one among several actors with the same action repertoire,
including pamphlets, rallies, demonstrations and occupations of treatment
organisations’ offices. Their chief goal was not to get better treatment, but rather
to be treated like other citizens with the same human rights, even if they were
using hard drugs. However, their situation was only made worse by the
prevailing drug policy. From the very outset, therefore, user organisations aimed
to change Dutch drug policy in terms of drug users having legal access to hard
drugs. However, such a fundamental change was a long-term goal; their shortterm goal was to improve the living conditions of drug users.
In 1981, “Junkiebonds” (Junkie Unions)42 emerged in a number of cities across
the Netherlands (Spuit 11, No. 3, 1981). The number of user organisations has
varied over the years from 15 to 30. Some have closed down, especially those
wholly organised by drug users, but many of them have returned with new, often
charismatic instigators (Jepsen 2004). In some cities, they are organised in
statutory associations or foundations, in other cities they consist of loosely
organised user groups.
The Emergence of Local Initiatives
Social problems tend to concentrate in big cities, and drug use is no exception.
The Dutch government was concerned that the drug problem might spread from
the cities to the rest of the country and therefore closely monitored developments
40
41
42
64
Problem use is defined as the use of a substance in such a way that it causes physical,
mental or social problems or social nuisance. Problem use does not always imply
addiction. “Misuse” is a type of problem use that it still not a matter of addiction
(Trimbos 2005).
Germany, Belgium and France, for example, adopted elements of harm reduction in
their drug policies during the 1990s.
The adoption of the concept of “junkie” (from junk, meaning rubbish), follows an old
Dutch tradition since the 16th century of reclaiming a derogatory name and using it as a
positive label of empowerment within one’s own movement (Vuijsje & van der Lans
1999). This is a case of framing that it is embedded in the cultural context.
in Amsterdam and the country’s three other major cities, Rotterdam, The Hague
and Utrecht, collectively known as the 4 G. The 4 G have played a major role in
drug policy issues since the 1960s, and they have discussed their local drug
problems and drug policies directly with the national government (Tops 2001).
This means that local initiatives also have an important impact on national drug
policy. Harm reduction practices, such as coffee shops and needle exchange
programmes, for example, first emerged in the 4 G before they became part of
national drug policy.
Likewise, drug user organisations have jointly pursued actions to influence
policy measures on the national level, and there have also been some national
drug user organisations.
The MDHG was founded in 1975 in a neighbourhood known as a marketplace
and gathering place for opiate users in Amsterdam, on the initiative of a local
resident who was convinced there should be viable alternatives to the repressive
drug policy (Hondius 2005). Among the other people involved were an outreach
worker, physicians, local pharmacists, users, and parents of drug users.
The National Dutch Federation of Junkiebonds (FNJB) was established in 1980
to promote the exchange of information between local user organisations and
discussion of developments and events at local and national levels. When
necessary, concerted actions were pursued. In June 1980, members of user
organisations in Amsterdam, Rotterdam and other cities occupied the premises
of the Federation of Agencies for Alcohol and Drugs (FZA), an umbrella
organisation for ambulatory drug treatment institutions in Bilthoven (near
Utrecht) and demanded to speak with the board in order to discuss its policy on
the prescription of methadone (Spuit 11, No. 4, 1981). Another example of the
ability of these organisations to carry out orchestrated actions is provided by the
conference staged by user organisations in response to the introduction in 1980
of compulsory care for hard drug users by the Lord Mayors of the 4 G. On this
occasion 500 participants, among them many drug users, gathered in The Hague
(the residence city) to discuss the proposal and to persuade public opinion and
politicians (MDHG 1981). Indeed this and other actions probably contributed to
the government’s decision to reject the proposal. In May the same year, at
another conference staged by user organisations, a proposal was floated for the
prescription of opiates (including heroin) to heroin users. This, at that time, was
a politically impossible option, but it was eventually realised twenty years later,
just as compulsory care. It was indeed a distinctive characteristic of national user
organisations at this time that they were very much oriented to direct action.
In 1992, another type of national drug user organisation emerged with the
foundation of the National Supporting Point Drug Users (LSD). The LSD was
established on the initiative of an ex drug user who had been previously involved
in a peer-to-peer harm reduction activity. The main goal of the LSD is to support
65
the creation of local drug user organisations. One of its functions is to mediate
between drug users and policy makers at both the local and the national level and
to provide advice in conflict situations between user organisations and treatment
organisations. It also aims to assist and encourage drug users to organise
themselves in local organisations. Other activities include the provision of
information about drug use and drug users at juvenile prisons and health care
institutions, to political parties, etc. Together with the Trimbos Institute, the
national knowledge institute for mental health care, addiction care and social
work, it has developed guidelines for the country’s 35 using rooms.43 In these
contexts, drug users should be considered “experience experts”.
The LSD received funding for its operation from the Department of Social
Affairs (VWS). As far as the VWS is concerned, “the LSD is like any other
association of clients, and it is important in the policy making process to know
what is happening in the world of drugs and drug users”.44 However, VWS
funding to the LSD had to be discontinued in 2005 due to cutbacks in the
national budget. The government’s policy today is to withdraw its funding for
activities that are a matter for local politics and authorities. How this will affect
local user organisations in the future remains to be seen. Organisations in the 4
G have now turned into professional organisations which (for the time being)
have stable resources and can survive even without the support of the VWS.
Organisations in smaller cities face a more uncertain future.45
It is probably because of its stable organisation that the MDHG has played an
important role in many of these initiatives on the national level and in networks
between local drug user organisations. The text below proceeds to look into the
aims and role of the MDHG in closer detail. It starts with a short description of
some important developments within the local Amsterdam drug policy.
Public Nuisance and Reducing Risks to the Environment
A significant change in local drug policies that influenced the everyday lives of
drug users was the launch of a programme aimed at reducing drug-related public
nuisance. The definition of this nuisance reduction policy and the way it was
implemented calls for some discussion.
In Amsterdam, an area near the Central Station46 was known since the 1960s as a
major marketplace for opiates: there were large numbers of opium users in the
local Chinese community and therefore the area also attracted opium addicts.
43
44
45
46
66
The term “injection room” is not used in the Netherlands. A large majority of drug users
smoke their heroin/cocaine and the premises are therefore called “using rooms”.
Interview with official from the Department of Social Affairs.
Interview with founder of the LSD.
This was the area in which the MDGH was established.
When heroin became the most widely used opiate, users began to gather in this
area. Heroin was of course available in others parts of the city as well, but the
sheer number of drug users here made them more visible. At first, the public
nuisance consisted mainly of petty crime, but eventually the mere appearance of
drug users was seen as a source of disturbance. Drug-related nuisance was most
noticeable around the Zeedijk, a street in the Red Light District, where drugs
were sold and used in the open. Local residents and shopkeepers consequently
began in the mid-1970s to insist that the authorities take action to intervene.
However, the complaints were not unanimous. For example,the present chairman
of the MDHG lived opposite the organisation’s offices and he initially took an
interest in the MDHG as he observed the people visiting the office from his
window. Furthermore, a letter from the Lord Mayor in which he advised people
in the area not to offer coffee, sandwiches or shelter to drug users, also goes to
show that not all local residents experienced the presence of addicts as a
nuisance (Spuit 11, Winter 2000).
In 1987 the police introduced what is colloquially known as the “Dike
prohibition”, which has been a thorn in the side of the MDHG ever since. This
local regulation gives the police the powers (in the name of the Lord Mayor) to
expel people from the area for up to eight hours if they are found consuming
drugs, if they are in possession of a drug-using device, or if they gather in a
public place in groups of four or more. At the same time, the individual or
individuals concerned will be summoned to court, where they will be issued a
fine of between 75 and 120 euros or given a five-days prison sentence. In cases
where people have received an expulsion order five times within six months, the
police can impose an expulsion period of 14 days. Violations may result in
prison sentences of six weeks to three months.
Another exponent of the nuisance policy in Amsterdam was the so-called streetjunkie project that started in 1989 and that was specifically aimed at a hard core
of some 300–400 problem drug users. Drug users who repeatedly committed
petty crimes more than four times during one year were given the choice of
either going to prison or attending a drug aid programme (Mol & Trautmann
1991).
A third example of the nuisance reduction policy is a penitentiary regulation,
SOV (Measure for the Criminal Care of Addicts), that came into force on an
experimental basis in 2001. According to this regulation a hard drug user who
has received more than three prison sentences and who is re-arrested within five
years, may be sentenced to compulsory care during a maximum period of two
years.
It is clear then from these examples that there are no grounds whatsoever to the
common notion that Dutch drug policy is liberal or permissive. This may be true
for cannabis users, but as far as problem users of hard drugs are concerned (and
67
particularly heroin and cocaine users), public and political attitudes are far from
liberal. As Mol & Trautmann (1991) have shown, Dutch drug policy has
followed an increasingly repressive course since the late 1980s. This new
direction, as we will see, became a major target for the MDHG’s action
programme, which was based on the view that is the “illegality of drugs” that
creates the black drug market and causes nuisance to the environment (Spuit 11,
Spring 2001).
MDGH: Working for an Alternative Drug Policy
The MDGH was founded as an alternative to the Netherlands’ repressive drug
policy in 1975. In a memorandum from 1977, the founder and first chairman of
the organisation proposed three starting-points, viz. a generous prescription of
substitutes (methadone, heroin and other opiates), ambulatory first line
assistance and a neighbourhood-oriented approach (Riemens 1977). When the
organisation turned into a union of drug users in 1981, its founder decided to
leave because in his opinion this move would lead to a further stigmatisation of
drug users (Hondius 2005).
Until 1986, the official name of the MDGH was the Association of MedicalSocial Service Heroin Users (MDHG); the name was then changed to the Interest
Association of Hard Drug Users (MDHG). The change from “heroin” to “hard
drug” users was made because hardly any of the members were on heroin only.
Since the 1990s, the organisation has been called the Interest Association for
Drug Users (MDHG). As the name of the organisation describes its main target
group, it is interesting to note that the MDHG no longer uses the epithet
“junkie”, a label that its constituency no longer appreciates.
It is the organisation’s position that the criminalisation of drugs and repressive
drug policy both adversely affect the social position of drug users and constitute
a major obstacle to the normalisation of drug users. The organisation conveys
this view in its contacts with politicians, the authorities, the public and the
media. Its main goal is to promote an alternative drug policy, including the
legalisation of drugs, and the normalisation, emancipation and public acceptance
of the drug user (MDHG 2004). In the shorter term, the organisation aims to
promote low threshold and user-friendly assistance programmes, including
methadone and heroin prescription, with a view to improving the everyday life of
drug users. Another goal is to work against the prejudice in society towards drug
users, especially in neighbourhoods where drug users live or gather.
The interests of the organisation’s constituency are promoted in numerous
contexts. The “user’s voice” is put forward in various fora; in contacts with the
judicial system, treatment institutions, the media and the polity. One way to
68
achieve influence is to get drug users involved in client councils of care
institutions, such as the municipal health authority in Amsterdam that runs
methadone programmes and the heroin prescription programme. According to
the Bill on Client Participation in Care Facilities (WMCZ) from 1996, all care
institutions are to have client councils in order to ensure client participation in
matters that are of immediate concern to them (NIVEL 2005). Another strategy
of gaining influence is through the representation of drug users on advisory
boards of projects such as the Measure for the Criminal Care of Addicts (SOV)
in Amsterdam.
Below, I describe some of the issues that have been raised by the MDHG as well
as activities and actions for and by its constituency. I make a distinction between
more or less regular activities directly aimed at the constituency and actions
aimed at the public and the policy-making domain. Together, these constitute the
organisation’s action repertoire.
Policy Challenging Activities
The MDHG is not a single-issue organisation, but its action repertoire covers
various aspects of the problems encountered by its constituency. It ranges from
challenging actions such as protest marches to the City Hall and occupying
institutions to more conventional information activities such as distributing
leaflets.
A recurrent issue concerns police activities to reduce drug-related nuisance, or
what the MDHG and its constituency regard as “police harassment”. Since the
1980s, the City of Amsterdam has been increasingly concerned about its dubious
reputation as a mecca for drug users, both in the Netherlands and abroad. In
1987, Amsterdam published its new drug policy in a booklet specifically aimed
at foreign drug tourists: “Addicts who are not from Amsterdam are not welcome
here. Amsterdam is not a rose garden for junkies” (Amsterdam Information
Office 1987). In the opinion of the MDHG, domestic junkies were not welcome
either, and the City’s message has been a main target for the organisation’s
activities and actions. Not surprisingly, this also accounts for nuisance reduction
actions such as the Street Junkie Project and the Measure for the Criminal Care
of Addicts (SOV).
The MDHG works to combat the “hounding junkies” policy in several ways. In
winter 1991, the organisation’s magazine Spuit 11 included four pages of
information for drug users on how to act in case they were arrested, detailing the
procedures as well as the rights and obligations of drug users and police officers.
In winter 2000, an allied (star) lawyer (and former member of the board)
prepared a standardised form of appeal to be used in case of a police summons
for violation of the Dike prohibition. In Spuit 11 (Winter 2000), drug users are
69
cautioned not to neglect a summons, but to bring it to the MDHG offices where
they will be assisted in filling out the form of appeal.
Another activity through which the MDHG works to combat the anti-nuisance
strategy is its “habituation course” for newly arrived police officers in the area,
informing them about the situation of drug users. This course imitates the
Netherlands habituation course that is obligatory for immigrants, who are
supposed to learn the language, the history, and the values and norms of Dutch
society. Another illustration of a more light-hearted action is the “Willem Schild
(an Amsterdam police officer) Award” for the user-friendliest police officer in
Amsterdam, launched in 2001. However, no police officer has be nominated for
the award since 2002.
The organisation’s action repertoire also includes more militant actions. On 19
September 2002, a group of 50 drug users entered a room where the Lord Mayor
was chairing a commission meeting, to protest against the police practice of
“hounding junkies”. The MDHG insists there is need for more using rooms. The
Lord Mayor was offered a peace pipe. He listened for a full hour, but rejected an
invitation to visit the MDHG for a discussion with drug users (MDHG 2003). As
the protesters made their way back, the police booked 15 of them for gathering in
the street (De Telegraaf, 20 September 2002).
The MDHG came up with an inventive strategy to circumvent the Dike
prohibition in 2004 when it established the Association Meeting Point and
claimed it was organising outdoor debates under the constitutional right of
meeting. By organising large numbers of meetings, the MDHG hopes to reduce
the number of fines issued for gathering. During these meetings, participants
wear a button which reads: “Do not disturb – meeting going on”.
Other issues addressed by the MDHG concern treatment arrangements, such as
methadone programmes and particularly the control practices and subsequently
the sanctions imposed through methadone programmes. It also closely monitors
the experimental heroin prescription programme. Complaints about the quality of
heroin used in the programme concerned its effects on the lungs when smoked.
Accustomed to street quality of diluted heroin, drug users were not used to the
purity of the prescribed heroin. Another target of criticism has been the
Amsterdam policy on using rooms: there are too few of them, they are far too
restrictive (users only have access if they are registered) and they are only open
during the daytime.
Self-help as Action
Although the organisation has explicitly stated that it is not a self-help
organisation, it does engage in activities that are directly aimed at catering for
70
the needs of its constituency. The best-known among its self-help activities was
the world’s first needle exchange programme in 1984. The initiative that started
out as a protest against the lack of sterile injection equipment eventually became
an integral part of regular drug treatment programmes. Other important activities
include practical support for members, for example in the form of assistance
with correspondence with social service agencies, making and keeping
appointments, finding a place to sleep, applying for an ID card or access to legal
aid. These activities are carried out in the streets, at drop-in centres, using rooms
or at the MDHG offices.
Another self-help activity is the so-called women’s afternoon. On Friday
afternoons, female drug users can meet female volunteers to talk about their
problems, get a massage, a haircut and smoke a little. This activity started in
protest of a decision by the municipality to close down a facility for female drug
users.
A more challenging activity that has been organised from the very outset is a
drop-in consultancy centre, intended primarily as a means for the organisation to
keep in touch with its constituency. Drug users can drop in for information,
advice, to complain or just to have a cup of coffee or a smoke. Opening hours
and days have been changed several times because of complaints by local
residents or orders issued by the police. Visitors represent a cross-section of the
drug using population in the area (and the prime target group for police antinuisance actions). In addition, wherever drug users meet and consume drugs,
drug dealers are not far away. Drugs have been used during drop-in hours and
tolerated by the staff. In 2004, however, the drop-in centre turned into an
unofficial using room with a daily average of 70 visitors. It was intended as an
alternative to established using rooms (nine rooms in 2005), most of which are in
the centre of the city, where drug users can smoke their heroin and cocaine.
These using rooms are run by assistance agencies, who also select and register
the visitors (in some cases visitors are also selected by the police), and their
main aim is to reduce the amount of nuisance caused to the general public by
drug use. Drug dealing on the premises is prohibited, and an experiment with
house dealers was ended in October 2004 when the police raided the MDHG
premises on suspicion of drug dealing. In the MDHG action plan for 2005, the
drop-in centre (“experimental self-management using room”) was described as a
success on account of its low-threshold character, and plans were announced for
its continued operation. However, not all local residents were pleased and
opening hours were reduced to three days a week (MDHG 2005). In April 2005,
the police raided the drop-in centre once again. After four months of
surveillance, the police had collected evidence of drug dealing, and this time the
Lord Mayor took the decision to close the premises. After discussions with the
municipality, the MDHG was allowed to reopen its offices on condition that the
drop-in centre remained closed.
71
The examples above show how the MDHG uses self-help activities for purposes
of achieving various goals. The women’s afternoon started in protest against the
lack of facilities for female drug users. The self-management using room,
launched as an alternative to the municipal policy on using rooms, was more
controversial and met with repressive actions. In particular, the house dealer in
hard drugs as a way of regulating not only drug use but also the retail trade of
drugs, challenged the very core of the national drug policy on hard drugs.
Obviously, in this case the limits were stretched too far.
Information Activities
Another important MDHG activity is the provision of information about the
organisation’s goals and its constituency to the media, the general public and the
authorities. Information is also provided on request, for example to the Police
Academy in Amsterdam. Furthermore, the MDHG participates in conferences
both in the Netherlands and abroad.
One important instrument in this information function is the quarterly magazine
Spuit 11, which has been published (irregularly) since 1981. It is edited by
MDHG staff and volunteers and it has around one thousand subscribers. The title
is rather ambiguous and relates to someone who always comes too late, but
“Spuit” is also the Dutch word for syringe. Reports about actions by the MDHG
and other user organisations are an important topic. Under the heading of
“Sounds of the Street” (or Junk mail), drug users report on their encounters with
the police or the treatment system, usually in critical terms. Occasionally, Spuit
11 contains obituaries of drug users who were actively involved in the MDHG.
Another, now defunct way of informing the public about the everyday life of
drug users was the open evening, which until 2005 was held every Thursday
evening at the MDHG premises. It was open to anyone interested, often with an
invited speaker addressing an issue related to drug use. Sometimes local
residents were invited to discuss problems allegedly caused by drug users, and
how to address these problems.
A standing subject of conversation at these evenings consisted of reports by drug
users about their experiences during the last week. This also provided an
opportunity for staff to keep themselves informed. A lawyer was also present to
provide advice, free of charge, to drug users who needed advice in legal matters.
The service ended last year because this voluntary lawyer retired and it was too
expensive to hire a replacement. However, the open evenings were not without
their problems because they were not intended as a drop-in for using drugs, but
for serious discussions, and these two activities did obviously not mix very well
(MDHG 2003). The staff placed a message (Sorry, no smoking, just talking) at
the front door, and eventually the open evening moved to Wednesdays (Jezek
72
2000). In 2005, the open evening was discontinued because it placed too heavy a
drain on personnel resources.
Another way to highlight the living conditions of the organisation’s constituency
is through research. One example of the MDHG’s research from a user
perspective is provided by a study (Dope and Detention) on the situation of
detained drug users (MDHG 1994). Furthermore, students from De Hogeschool
van Amsterdam conducted a study on the subject of coping with bereavement
among drug users. The study explores the question as to how far it is possible to
mourn while using drugs and looks at the role of treatment in this process (LSD/
MDHG 1999). The MDHG was also involved in a study called Free heroin…
Medical prescription from a users’ perspective conducted by the LSD in five
cities where 40 drug users were interviewed (by drug users) about their
experiences of the heroin prescription programme (LSD 2002).
As mentioned earlier, the MDHG has also played an important role in national
initiatives and in establishing contacts between local drug user organisations.
One example is the “four cities consultation” in which representatives of user
organisations in Amsterdam, Rotterdam, The Hague, and Utrecht meet four
times a year to discuss developments in their cities and in national policies – an
analogy to the meetings of the Lord Mayors of the 4 G. Here it is interesting to
consider the impact of the social context both on framing activities and on the
creation of networks through the high population density, which facilitates
communication and mobility. The Netherlands is one of the most densely
populated countries in the world; by comparison drug users from Stockholm and
Malmö in Sweden, for example, would have to travel 600 km to meet each other.
The MDHG also participated in the preparation of the annual International Drug
Users’ Day, organised by the LSD until 2003 and financed by the Department of
Social Affairs. At this meeting drug user organisations from around 20 countries
got together to exchange information and experiences.
In summary, the MDHG’s action repertoire is multifaceted, ranging from support
to drug users in everyday matters through political actions to research. It is also
noteworthy that the issues covered and the activities and actions pursued have
been remarkably stable over time. Tensions between what the organisation wants
to achieve and the conditions embedded in its structure and social, political and
cultural context are discussed below.
Dilemmas of Representation
An important issue in terms of representation is whether a user organisation is
organised for or by drug users. Some take the view that only users can represent
themselves. Others refer to the circumstances in which drug users live their lives,
73
very much hampering their ability to run a stable organisation. So what kind of
organisation does the MDHG actually represent. Kriesi (1996, 154) outlines two
ideal types of organisation that are of interest here. First, there is the grassroots
model, which is characterised by a relatively loose, informal, and decentralised
structure, an emphasis on unruly, radical protest politics, and a reliance on
committed adherents. Secondly, there are interest organisations that are
characterised by an emphasis on influencing policies (via lobbying, for instance)
and a reliance on formal organisation.
The MDHG describes itself as an interest organisation for and by drug users.
Even though it has attempted over the years to encourage stronger grassroots
participation, its main feature remains that of a formal organisation. The MDHG
is open to drug users, ex drug users, their relatives, and all others who share the
goals of the organisation. Non-drug using supporting members do not, however,
have a vote at the annual meeting (Spuit 11, Winter 1999). As from 1977, the
MDHG has been formally organised as an association with a board consisting of
five to seven members. The board is elected by the members every three years. It
accounts for its work (and that of staff members) in an annual report submitted at
the annual meeting, which is also where questions of policy and activities for the
next year are decided. The members of the board are elected on the basis of their
commitment to the issue and their professional affiliation; they include lawyers,
staff members of drug assistance organisations, scholars, but also parents of drug
users. To ensure that the organisation’s constituency retains a voice, the board
always includes at least two drug users. Among the board’s several functions, the
most important is to guarantee continuity in the organisation.
A common difficulty for user organisations that hope to be an organisation for
and by drug users is how to actively involve users in activities within and outside
the organisation. Since the use of hard drugs is illegal, users often find
themselves preoccupied by obtaining drugs and therefore have no time for
organisational work. On the other hand, if and when users do succeed in
obtaining drugs, that may also undermine their ability to work for the
organisation. Furthermore, drug users occasionally end up in prison or die. These
problems also apply in the case of the MDHG. According to the organisation’s
director, it is very hard to encourage members of the constituency to attend
annual meetings, for example, and consequently drug using members usually are
in the minority.
The board also has a responsibility as an employer. The working relation
between the board and staff members can vary from a rather distant one to a
more active interplay. Today, contacts are close and the director and the board
meet every other month. Staff and volunteers who have daily contact with the
constituency can address issues that are important to them.
74
Financial Resources
Financial and human resources are important to the development of a social
movement organisation and affect its internal structure. The MDHG depends on
the municipality for financial resources, which means that it has to give
something in exchange, such as services that the regular assistance system
cannot adequately provide. As in other countries, the spread of HIV among drug
users has dramatically increased the availability of financial resources for HIV
prevention activities (Tops 1991). User organisations suddenly became
important allies for public health authorities, for example in peer-to-peer
campaigns for the prevention of HIV. In other words, the flow of financial
resources very much influences the organisation’s activities.
Since 1977, the MDHG has been subsidised by the City of Amsterdam, and it is
currently subsidised directly by the Office for Social Development (DMO). One
of the office’s tasks is to assist district councils in developing and executing
services in a number of fields, including the care of drug users. To “earn” this
subsidy, the MDHG has to advise the DMO on such matters as when a district is
planning to open a using room. Another minor source of income is a subsidy
from the Amsterdam Patient and Consumer Platform (APCP), which is based on
the number of members. In April 2004, the MDHG had 1,200 members, about
half of whom were supporting members.47 For 2005, the organisation’s budget is
150,000 euros: this has to pay the salaries of full-time staff (director, secretary
and assistants), the office rent, the magazine Spuit 11, etc. In summary, the
MDHG is a formal and professionalised organisation that largely works for its
grassroots members, i.e. drug users.
The mode of financing can also bring about a certain level of professionalisation,
including staff appointments. MDHG staff consists of a co-ordinator, regular
staff members and assistants (usually drug users employed with labour market
subsidies from the state or municipality for a maximum period of two years).
While daily operations are in the hands of the director and secretary, the
assistants are busy with activities directly aimed at the constituency, such as
running consultancy hours or visiting drug users in using rooms or in the street.
For assistants, the job provides an opportunity to stabilise their drug use and
social life. Much of the organisation’s activities are based on the commitment of
volunteers. However, doing voluntary work in a user organisation is no easy
task, and requires the ability to communicate with people who are not always
organised or prepared to put the interests of the organisation first (LSD 1998).
47
Interview with the director of the MDHG.
75
Co-optation
After 30 years at the same location, the MDHG moved in September 2005 to
new premises. The main source for its subsidies, the Office for Social
Development (DMO), stressed that the MDHG should find new offices in
affiliation to an assistance organisation. 48 The MDHG, however, preferred to
remain independent and finally found a new location on the edge of the city
centre district, much against the will of the district council and police
authorities: they took the view that assistance agencies should move out of the
district because they attracted drug users. However the MDHG was allowed to
reopen on condition that it organised no using room activities on the premises.
Now, the MDHG has consultancy hours on an individual basis from nine to five
every day. This enables the organisation to pursue one of its most important
tasks, namely to understand the problems encountered by its constituency. Other
ways in which this can be achieved is for staff members to visit drug users at
using rooms and other locations.
These latest developments highlight some interesting issues. First, they draw
attention to the tension between two elements of the organisation, i.e. its
ambition to represent the grassroots members who have only limited ability to
organise themselves, and on the other hand its role as a formal professional
organisation that works for its constituency, the grassroots. Secondly, they
highlight the risk of co-optation, with the organisation becoming ever more
closely integrated into the official assistance system and in this way making it
harder to criticise the system.
In the MDHG’s 2002 annual report, the chairman of the board cautioned against
excessive involvement in all kinds of consultations with the authorities, because
these consultations can also be exploited to legitimise drug policy decisions. The
organisation is at risk of getting bogged down in endless meetings, while the
constituency is keen to see action (MDHG 2003).
It is possible that the MDHG will slowly, but obviously not unnoticed, become
involved in a process of institutionalisation and formalisation in order to ensure
its access to a stable flow of resources. This will obviously influence its internal
structure and its integration into established systems of interest intermediation.
However, the organisation has managed to avoid some of the consequences of
such a transformation: for example, it has neither moderated its goals nor
conventionalised its repertoire. Furthermore, it has resisted demands by funding
bodies to affiliate with assistance agencies. As for its internal structure, the
organisation has shown long-standing stability, presumably due to its structure as
an association. However, there are also some signs that at the staff level, things
are changing. Today, the co-ordinator has the title of “director”, and the 2004
48
76
Interview with the director of the MDHG.
annual report of 2004 features the terms “managing director” and “finance
director” (MDHG 2004) This professional approach is probably also reflected by
Spuit 11, which today is a glossy magazine. Whether this is simply an
adjustment to the changing social structure or a fundamental change in the
organisation’s internal structure, is as yet unclear.
Future Challenges: Stretching the Limits
User organisations have been a common social phenomenon in many Dutch
cities since the 1970s. Although many of them have disappeared over the years,
some have shown great strength of survival and maintained their activities. The
MDHG provides a good example. One of the reasons for its strength is that the
organisation is an association with a board consisting of both non-drug users and
drug users, which has provided a stable structure over time. Secondly, the
presence of a professional staff also contributes to stability. Thirdly, a steady
flow of financial resources is important for any organisation. The MDHG is an
organisation for rather than by drug users, and its main task is to promote the
interests of drug users in contacts with the policy-making domain, treatment
systems and the media. To achieve these goals, the organisation has to be in
close contact with its constituency, either through drop-in consultancy hours,
open evenings (until 2005), individual contacts in the street, using rooms, or
treatment centres.
Looking at the political context, it is clear that local authorities are important
actors on the Dutch political scene. Dutch drug policy is largely an outcome of
local developments, although it is also constrained by international
commitments. Dutch user organisations therefore operate mainly on a local level,
because it is there they can make a difference for their constituencies – and hope
that their actions can make a difference at the national level as well. The
emphasis on local activities can be explained by the historical social context. In
the process of state making and in drug policy issues, the largest cities in the
Netherlands (the 4 G) have played a dominant role since the 1960s (Tops 2001).
However, as the MDHG itself has found out, it is very hard to gain access to
decision-making processes. The MDHG still has no part in commissions that are
involved in activities directly aimed at drug users. However, the MDHG can
influence the local policy-making domain through its official mission at the
Office for Social Development (DMO), namely by putting forward the voice of
drug users. Another avenue of influence is through participation in client
councils, but here again there is the question as to who represents whom. Even if
drug users have a representation in client councils, the difficulty remains as to
how to keep in touch with the constituency they represent. A third way of
gaining access to decision-making fora is through the professional networks of
77
board members. A fourth, indirect way is by seeking to persuade politicians
through the media. It is of course hard to assess the true influence that the
MDHG has on the policy-making process. However, the frequent appearance of
the organisation in the media suggests that the MDHG is at least thought to
speak on behalf of drug users.
Another intriguing question concerns the rationale behind the municipality’s
decision to subsidise an organisation that over the years has been one of the
fiercest opponents of the City’s drug policy, particularly its “hounding junkies”
policy. The same applies, until recently, to the national government. There are
several possible answers to that question. Firstly, as pointed out by the MDHG
chairman, (limited) involvement by the organisation in the local drug policy
domain can be exploited to legitimise policy decisions. Secondly, the MDHG
performs functions that are not possible for the established assistance system. A
third possible explanation relates to the structure of the treatment and assistance
system in the Dutch social/cultural context. For historical reasons, the bulk of
social and health services are organised and executed by non-governmental
organisations, which means that national and local authorities depend heavily on
these organisations in pursuing a policy. Consequently, this institution with long
roots in the past opens up opportunities for new actors in this sector.
There is yet another salient feature of the Dutch cultural context that should be
mentioned here. Dutch society is often described as a “consultation nation”
where special value is attached to the achievement of consensus between
conflicting parties (Andeweg & Irwin 1993; Lendering 2005). The Dutch even
have a special word for this that goes back several centuries: “polderen” means
that relations between central government and the cities, between the cities and
their citizens, between employers and trade unions, etc., are dealt with in
deliberations between the two parties. This time consuming procedure, which
may involve an indefinite number of meetings, might be considered a rather
ineffective way of decision-making, but it has in fact proved to be quite effective
in reaching consensus. This might explain why the policy-making domain
refuses to neglect the socially and politically marginalised minority of problem
drug users, but on the contrary finances and consults their organisations.
Obviously, the City of Amsterdam seems to be of the opinion that the
organisation holds an important intermediary position between drug users and
the drug policy domain and the treatment system. Otherwise, it would be hard to
understand why it has subsidised the organisation for over 25 years.
One aspect of the social context is represented by national and local drug
policies. The harm reduction approach adopted in the Netherlands is described as
relatively successful when compared to other European countries (VWS 2003).
In 2003, the number of problem hard drug users in Amsterdam was estimated at
4,530 (Trimbos 2004); some 1,000 of them are categorised as extremely
78
problematic (Amsterdam 2005). The average age of methadone clients in
Amsterdam in 2003 was 44 years (32 in 1989), 51 years among drug users born
in the Netherlands and 42 years among those born abroad (Trimbos 2004). The
mortality rate among problem drug users is relatively low, and consequently a
considerable number of drug users are still alive and constitute a residual group
of the drug using population. This group consists of people who are homeless,
who suffer from psychiatric problems, are in a poor physical condition and use
drugs – indeed a very vulnerable group with which neither the drug treatment
system nor the police seem to be able to cope. It is clear from this that there is a
need for alternative activities such as those carried out by the MDHG and that
partly form the organisation’s raison d’être.
Another relevant social aspect is that many drug user activists belonged to the
generation that grew up during the 1960 and 1970s. Most of these first
generation activists are now dead or have left the drug scene, a fact that may
emphasise the need for a formal user organisation. If the MDHG had been solely
an organisation by drug users, it is hard to imagine it would have celebrated it
25-year jubilee.
The MDHG has survived as a social movement organisation without changing its
goals and even without making many changes to its means of action. However, it
is possible that structural changes in its external environment are forcing
changes in its internal structure as well. For example, there is the legal obligation
since 1996 for all institutions that provide care or treatment to establish a client
council or to have client representatives on their board. This regulation might
have the effect of formalising and canalising user influence. The requirement
introduced in 1999 that all member be registered in order that the organisation
qualifies for subsidy, or the professionalisation of the organisation’s
management, may also contribute to formalisation. This process also includes the
creation of a formal leadership and office structure, leading to
professionalisation with a management of directors and paid staff members.
However, the staff by means of actions like the self-management using room and
conflicts with its financiers, has demonstrated that the process of
professionalisation does not necessarily impair the action repertoire.
As regards external structures, the organisation depends on two main sources of
income, one of which is also a target for its actions. This puts the organisation in
a classic dilemma, that of co-optation. The creation of client councils not only
opens up opportunities to influence treatment practices, but may also lead to cooptation. This is something the organisation clearly is conscious of, but which is
hard to escape from. Participation in all kinds of councils and working groups
can be a double-edged sword. It can provide an opportunity to exert influence
and promote the interests of the constituency, but on the other hand the
organisation may also be inundated by the flood of meetings and deliberations. It
can also make it difficult to take direct action, such as obstructing the police or
79
occupying offices of treatment organisations. In this situation, the organisation
has to decide to take part in legal/illegal actions. In the case of the consultancy
drop-in centre that turned into a using room, the MDHG obviously crossed the
line and the centre was closed down. At this point, the organisation has to
maintain a balance between being both a grassroots organisation and an interest
group. The tension between being an interest group and providing assistance to
members is also a delicate one because assistance activities such as a large scale
drop-in centre takes up a lot of resources at the expense of the interest promotion
side.
If the organisation is forced by its political and social context into one type of
movement organisation, then it has to decide which direction to take. If it
chooses to become a pure formal interest group, then it may risk losing contact
with its constituency. However, if it chooses to become a pure grassroots
organisation, then it risks losing its financial resources and influence in the
policy making process. A delicate balancing act indeed.
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82
Democracy or Closer Control?
Emergence of Drug User Participation in Norway
Astrid Brandsberg Willersrud & Hilgunn Olsen
Introduction
We give here an account of the current status in Norway on drug user
participation in drug-related policy making and intervention design. The past ten
to fifteen years have seen major developments not only in respect to public
policy means and ends, but also in treatment, health and social care legislation.
Alongside these developments, in the last decade user organizations and active
drug users are increasingly prepared to go public in defence of their interests.
That political and healthcare authorities increasingly express that they consider
user interests both important and timely represents a relatively unfamiliar
situation in Norway.
We ask therefore why the authorities want to bring a historically so marginalized
group on board at this particular point in time. What started the ball rolling in
Norway in the mid-1990s? We compare user organizations to be extant 1996–
2004, asking what unites them and, conversely, what divides them. Do user
organizations foster a sense of empowerment among individual users? How well
do they discharge their role as participants in public policy making? Is society
ready to listen to what users really think, including views which even by today’s
liberal standards could be called politically incorrect? Or are politically “safe”
organizations more likely to catch the ear of policy makers? We discuss below
the relevance of concepts of power and social control in relation to the user
perspective on this group.
We define “user” here as a person who uses illegal substances regularly; “former
user” is a person who has been a regular user but has stopped using drugs.
History of User Participation in Norway
The user perspective and user organization are two relatively recent phenomena
in the field of drug policy in Norway.49 It was only with the emergence of HIV
49
Homeless alcoholics formed an action group in the 1970s following the
decriminalization of public drunkenness. Homeless people became more conspicuous,
83
and AIDS in the late 1980s, followed by methadone substitution treatment which
became available in the 1990s, as the decade became increasingly focused on
health and care, that the first user organizations were formed. This should be
seen as a part of the general perception at that time of drug use as a law and
order issue, where the police and the judiciary until then had had the major role
in fighting drugs and thereby also drug users. Indeed, between the 1960s and
early 1990s, consensus united all political parties in Norway on the idea of an
ultimately drug-free society (see e.g. Stortingsmelding nr 13, 1985–1986;
Andenæs 1994). Users were in consequence generally ignored; not even on
matters related to their own situation were they consulted. Prevailing public
policy and treatment ideology gave users a simple choice: stop using drugs and
become “good citizens”. Giving up the habit was conceived largely as a matter of
willpower and morals, and neither medical nor biological approaches were given
headroom in the “social education” model in vogue at the time (see e.g. Watten
& Waal 2001). Drug users who would not or could not kick the habit were
considered weak, low on moral fibre, a threat to the established social order and
coming generations (see e.g. Christie & Bruun 1985). It is therefore not
surprising people saw users as a public enemy, nor that politicians and the media
neither sympathized with nor showed much interest in what users themselves
might think or feel.
But as HIV/AIDS became an increasingly urgent issue in the late 1980s, user
participation was aired as a means of improving HIV prevention among injecting
drug users (Blindheim 1999). It was quickly forgotten, however, possibly
because initial efforts aimed at HIV/AIDS and users were justified by inflated
fears of a society in jeopardy, less about what benefited the drug user (see e.g.
Skretting 1997; Brandsberg-Dahl 2000).
There was no structural nor social context then to enable users to articulate their
views or indeed be heard (see Rucht 1996); a notion like “user participation” had
simply no currency in the political climate and therapeutic ideology of the 1980s
and early 1990s.
So what happened on a rainy June day in 1997 surprised many people. Who
would have expected the most run down elements of the Oslo central station
group of users to stage a protest march along Oslo’s main thoroughfare bearing
homemade placards, stop outside parliament and proclaim their demands? In the
days running up to the march, a core group of activists had handed out leaflets
among fellow users, and they marched with a sense of purpose through the
centre of town – headed by the mounted police. For the first time, the voice of
and were blamed for the rise in robberies and assault. They attended public consultations
arranged by the city council, and it is said the action group brought about a change in
policy to their advantage, with greater attention given to their difficult circumstances
(see Mathiesen 1975). The campaign proved short-lived however.
84
the ostracized was heard at the centre of national politics. Politicians’ refusal to
meet the marchers was something the media were quick to seize on in their
reports (Aftenposten 21.06.1997; Arbeiderbladet 21.06.1997; Demonstrasjon for
metadon 1997). This event could be taken as symbolizing a sea change in
Norwegian drugs policy, insofar as users presented themselves as ordinary
human beings – with opinions about their own “hopeless” situation, and the
“impertinence” to demand a hearing.
Sinners or Sick?
By the mid-1990s, policy makers and healthcare authorities in Norway were
beginning to espouse a more person-centred approach, targeting harm reduction
measures at individual users (see e.g. Skretting 1997; Alcohol and Drugs in
Norway 1998; Brandsberg-Dahl 2000). It was prompted by the large number of
drug users, including those who rejected help towards a drug-free life, whose
needs the welfare state could no longer ignore on ethical or moral grounds. A
record mortality rate was another key factor behind the change in strategy.
Mortality rates in Oslo in the mid-1990s were embarrassingly high compared
with other European cities. In the 30–39 age-group, mortality increased rapidly
between 1990 and 1995: 29 died in 1990, 49 in 1993, and as many as 84 in 1995.
Mortality in the 40+ age-group rose several hundred per cent over the same
period, from 3 in 1990 to 26 in 1995. Mortality rates in the 15–19 and 20–29
age-groups remained relatively stable, however (Alcohol and Drugs in Norway
1998, table 2.2; see also, e.g. Frantzen 2001). Overdose deaths continue to rise
sharply in the late 1990s, from 148 cases in 1997 to 338 in 2001. As of writing,
mortality rates have stabilized at a relatively high level (Kouvonen 2006).
These figures should be seen as contributing to a more realistic approach among
policy makers and health officials to the often limited rehabilitation prospects of
the eldest and most run down drug users.
On January 1st 2004, responsibility for drug users and therapeutic institutions
devolved to the ordinary health service and came under healthcare legislation.
On September 1, 2004, the scope of the Patient Rights Act was extended to
include users of illegal substances. According to the provisions of the Act users
have a right to be informed and consulted (Bedre behandlingstilbud... 2004). One
of the purposes of the amendment was to strengthen the rights of users to
treatment and to be consulted on issues affecting their everyday life. The
amendment sought further to ensure users with special needs and/or other
somatic disorders and problems were dealt with more effectively by healthcare
professionals and hospitals. Heroin users admitted to hospital today are often
prescribed methadone to relieve abstinence symptoms even when they are not on
a methadone substitution programme. This was unusual before (Watten & Waal
85
2001), when opiates were still a controversial method of treating abstinence,
practised only by the state-run methadone programmes. Users dependent on
heroin may well have found it difficult to consent to necessary treatment if it
required hospitalization. We note, then, a change in the official status of users in
Norway, from client to patient, and from “criminal” to “sick”. In other words,
from representing a problem to having a problem.
Participation as a Means of Control?
How much better and easier it is to be a user today is difficult to say. In our
opinion, it is not necessarily very easy. Wide-ranging structural and attitudinal
changes are required before the life chances and status of a particular group are
likely to improve, especially when the group in question is as marginalized and
condemned socially and morally as drug users continue to be. Much more is
needed than a new terminology and redefined concepts to change entrenched
structures. It is easy to let new designations obscure the fact that old approaches
are still largely at place, contrary to general belief (Christie 1982). Christie says,
for example, when discussing terminological changes in the correctional and
probation sector, that
Pain and suffering have disappeared from the textbooks and the labels attached
to the measures. But not, clearly, from the experiences of inmates. (ibid.: 17)
Addressing these issues, French philosopher and sociologist Michel Foucault
saw society’s definition and exclusion of criminals, the mentally ill, gays and
other deviant groups as an expression of power and a function of power. This is
particularly pertinent in the history of the correctional system and psychiatry
(Foucault 1973 & 1977) – where the overriding aim of control of deviant groups
is essentially the same, despite modernization and terminological facelifts.
Coming at the issue from this angle, there is no room for a concept like user
participation, at least not in any significant sense, because deviant individuals
perform a service to society by their very definition as deviants. The concept
could, however, help ensure closer control of deviant groups, for instance by
empowering them nominally rather than substantively. In a Foucaultian
perspective, methadone substitution treatment is today’s version of the
incarceration of users practised fifteen years ago, the control of a specific
deviant group by established power structures to enhance their legitimacy and
raison d’être. There is no point in claiming this as an underlying motive of
policy makers in Norway today. But at an aggregate level, user participation
could become a device which enhanced the legitimacy of established structures
if users are encouraged to join in, but not taken seriously.
86
The Thinking Behind Harm-reducing Measures and
Methadone Substitution Treatment in Norway
Before the 1990s it was extremely rare to see the media criticizing alcohol and
drug policies and attitudes. In fact, the media, in their role as merchants of doom,
helped justify in the eyes of the public, a strict policy of control by judicial
means. It was simply incorrect politically to criticize alcohol and drugs policy,
its intentions and instruments – and people who did were simply ignored
(Andenæs 1994). The ’90s changed all this, abruptly and comprehensively.
Statistics (such as those compiled by SIFA in 1998) indicated a rising population
of substance users and growing market for illegal drugs despite decades of
repressive control and relatively robust therapeutic interventions (Skretting
1997). The findings were shocking. Politicians started to criticize current policy,
and debates which only a few years before were inconceivable (such as the
discussion on distributing heroin) became daily fodder in the mass media within
a few years. Danish and Swiss approaches were explored in detail, particularly
steps to ease access to methadone, heroin dose distribution and special facilities
where users could inject safely. Some politicians believed these ideas were
worth trying out in Norway as well (Aftenposten 29.08.1995, 30 & 31.08.1997;
Arbeiderbladet 03.09.1997; VG 29.09.1997; Dagbladet 13.08.1998).
It was also becoming clearer at the time that Norway had a growing population
of elderly, sick, impoverished users, who in their destitute state were
increasingly conspicuous, particularly in the capital. The response of society was
generally one of sympathy and compassion, not the disgust and fear. People
didn’t deserve to live like this in the welfare state. Rising mortality rates noted
above in the older age-groups probably accelerated the change in public attitudes
towards users. There is little doubt that the media played a key role in this
process, not only as a vehicle for debate, but by portraying the people concerned
in a more positive light, more offended against than offending (Brandsberg-Dahl
2000). It is therefore safe to say that the media played a crucial (if somewhat
selective) role, furnishing evidence and information and framing the political
agenda. Conventional roles were turned upside-down, with the erstwhile enemy
of society (the user) transfigured into victim, and the once sorely tested victim
(the state) now acting the part as public enemy number one (Christie & Bruun
1985; Brandsberg-Dahl 2000). Alongside these political, cultural and social
structure shifts in alignment, drug use was increasingly seen as a medical and
biological phenomenon. Where individual and social psychology once prevailed
as explanatory models, modern medical and biological explanations became
increasingly popular (see e.g. Watten & Waal 2001; Skretting 1997). It is a
global trend in fact, the increasing tendency to explain drug addiction
biochemically and genetically.
87
In the 1990s then, social, cultural, political and theoretical contexts changed in
Norway. In line with Dieter Rucht (1996), all these elements are essential to the
mobilization of resources (“user involvement”) of a largely powerless group of
people. These various developments affect each other, of course, and with regard
to alcohol and drugs, a new national context gave credibility to how users
viewed their personal situation. Why these developments happened more or less
at the same time, facilitating wide-scale, rapid change, may have something to do
with the enduring period of stagnation that went before. The policy area was
simply ripe for change, and rising mortality figures in the 1990s, the AIDS/HIV
“epidemic” and focus on a comprehensive healthcare system which had failed so
signally to rehabilitate users, provided the triggers, and explain why change
didn’t come sooner.
The watershed event of the ’90s was the methadone substitution programme,
MiO, a four-year trial conducted in Oslo. It was controversial politically and
medically, and, not surprisingly, descended into a “trench war” mentality, laced
with prejudice, ignorance and absence of evidentiary substance on all sides. It
was a sea change in relation to the established therapeutic approach, with its
focus on rehabilitation and a drug-free life, where medicine and biology were
non-starters (see e.g. Skretting 1997; Brandsberg-Dahl 2000). The project was
up and running by autumn 1994, if not without considerable teething problems.
But it is precisely here we find the origins of Norway’s first user organization,
founded in 1996. That methadone substitution treatment is so directly linked
with the emergence of a user perspective is not as surprising as it might seem at
first glance. Medicine as a means of controlling deviant behaviour and
marginalized individuals has a long history, especially in the psychiatric field
(see e.g. Conrad & Schneider 1992; Kringlen 1996). We define medical social
control here with Conrad & Schneider as
the ways in which medicine functions (wittingly or unwittingly) to secure
adherence to social norms – specifically, by using medical means to minimize,
eliminate, or normalize deviant behaviour. (1992, 242)
Methadone substitution treatment for people addicted to heroin comprises a level
of patient control, insofar as patients are as physically dependent on a daily
methadone dose as they were on the daily heroin dose. One important aspect of
methadone treatment (and other drugs that cause dependency) is that it is not
motivated by a desire to control a recalcitrant group of people while pretending
to offer treatment, as Foucault writes, but forms part of an integrated strategy
based on sound therapeutic thinking to improve people’s quality of life and reestablish a sense of dignity. Because methadone substitution treatment unleashed
strong political and medical sympathies and antipathies, it came to be seen as a
form of rehabilitation leading to freedom from drugs, which in turn
automatically led to a higher level of patient control (see e.g. Skretting 1997;
Brandsberg-Dahl 2000). Recently, however, as treatment is increasingly adapted
88
to patient needs and coping skills, the control aspect of methadone substitution
treatment in Norway has receded somewhat.
To methadone users, control of the drug can seem rather severe at times. They
feel relatively powerless vis-à-vis the therapists: by withholding the daily dose of
methadone, therapists can cause users to become physically ill. Users in
medication-free treatment have greater control over what happens to them – and
in the event of an insoluble conflict, they can get up and go. A radical solution
like this is not available to methadone users, most of whom would consider the
loss of their methadone a disaster they would do “anything” to avert (Ervik 1997;
Frantzsen 2001). In this light then, methadone could be used to control users, and
for that reason, users, by virtue of their new status as patients are more likely to
press their case and stand up for their rights than before.
User Organizations and Associations in Norway 1996–2004
The ’90s were the decade when users’ idea of forming an organization came to
fruition. Previous efforts had never met with tangible success, but seeing that
methadone users took the lead, other user groups joined in. In what follows we
look back on the emergence of the leading national organizations and
associations and highlight similarities and differences. Despite differences
however, they face relatively similarly challenges and issues.
The table below breaks the major organizations down into three classes: 1) those
that are run for and by active users; 2) those that are run for and by former users;
3) those that are run for and by methadone users.
Active Users
Former Users
Methadone Users
Drugs Policy Association
(Narkotikapolitisk forening,
NF), establ. 1970s.
Recovered Addicts’ Interest
Organization
(Rusmisbrukernes
Interesseorganisasjon, RIO),
establ. 1996
Methadone Users’ Interest Group
(Metadonbrukernes interessegruppe, MIG-96), establ. 1996
Tønsberg Users’
Association
(BrukerForeningen i
Tønsberg, BFiT), establ.
1999
Users’ Interest Group (Brukerens
interessegruppe, BIG-98),
establ. 1998
LAR-NETT, establ. 2004
Oslo Association of Users
(Oslo Brukerforening,
OBF), establ. 2000
89
The organizations for methadone users are Metadonbrukernes interesseorganisasjon (Methadone Users’ Interest Organization), Brukernes
interessegruppe (Users’ Interest Group) and LAR-NETT. As noted above, the
Methadone Project in Oslo (MiO) was surrounded by controversy and debate.
The project’s patients formed the “Methadone Users’ Interest Group” – MIG-96
– in 1996, with a view to promoting their own treatment-related interests, raise
public awareness about methadone treatment, establish a positive image of
methadone users and encourage a more humane therapeutic approach and make
the treatment more widely available. This organization worked within the
framework of an existing methadone project and did not promote the interests of
other users. MiG-96 established good relations with the methadone project
management, and was welcomed as a positive and serious organization. One
thing the Methadone Users’ Interest Group accomplished was to extend access to
a “Thinktank” (Ideverkstedet), a council-run shelter and activity centre for
former users and users in rehabilitation, to methadone users. Their interest
organization therefore lodged a complaint with Oslo Alcohol and Drug
Addiction Service, resulting in a lifting of the ban in 1997 (Ervik 1997).
When the expanded Methadone Project in Oslo was put on a permanent footing
in 1998, the Methadone Users’ Interest Group was replaced by the Users’
Interest Group/BiG-98, by which time the initial organizers had stepped down.
Users’ Interest Group/BiG-98 received no financial support, and could be
described as an organization with ambitious ideas but a relatively unstable
leadership. Activity levels fluctuated, reaching a low point in 2004. One
individual in particular worked hard to promote BiG and empower methadone
users, but experienced highly variable contributions from other users. He is
surprised, he says, at the low level of interest in working for user participation
and promoting the organization (Frantzen 2005).
The history of the Methadone Users’ Interest Group/ MiG-96 and Users’ Interest
Group/BiG-98 serves to illustrate the challenges facing this type of user
organization. Several methadone users used other substances regularly treatment
notwithstanding. Some came to meetings with MiO management while still
under the influence, and were simply not taken seriously. The stable, resourceful
person whose efforts led to the organization’s establishment had departed, partly
because he felt others were destroying what he had built by representing the
organization while they were doped.50 It is difficult to see how members of
MiG-96, given certain exceptions, could have made much of a difference. How
difficult it can be to organize users is illustrated by an event that took place in
the autumn of 2004. There was widespread dismay among methadone users with
the way the project was going. BiG’s prominent leader therefore arranged a
50
90
The author Astrid B. Willersrud worked at the time at MiO, and observed events at first
hand. She also made a telephone interview with the leader (in March 2004) where he
described the situation and the reason he stepped down.
meeting with the project management where users could air their grievances. In
the event, only seven methadone users showed up.
LAR-NETT51 is the latest organization to seek user empowerment. LAR-NETT
designates itself a forum for users. The first national conference for drug users
took place on October 11, 2004. Entitled “Metaphor” and arranged by
methadone users it explored the issue of “user participation”. To the organizers
the conference represented the “definitive breakthrough” for the user forum
approach in Norway. LAR-NETT’s membership is mainly people undergoing
substitution treatment, but users, professionals, family/friends and others are
welcomed too.
The three organizations of active users are Narkotikapolitisk Forening (Drugs
Policy Association), BrukerForeningen i Tønsberg (Tønsberg Users’
Association) and Oslo Brukerforening (Oslo Association of Users). The Drugs
Policy Association is not a membership organization; it works as a pressure
group and agenda-setter in the area of drugs policy. Its history stretches back to
the 1970s, but it was dormant for many years. Today, its prominent leader gives
the organization a face in the media, and has about fifty letters/articles published
yearly in the print media.
Tønsberg Users’ Association (BFiT) was formed in 1999 to promote the social
and societal interests of drug users, and provide support and advice for members.
It derives its inspiration from the Danish Drug Users’ Union (Brugerforeningen).
It is an organization for active users and has concentrated on normalizing
substitution treatment, making it more “socially acceptable”. Here too a few
prominent individuals have featured in the media; it is difficult for outsiders to
know how much activity there is in the organization.
Oslo Association of Users is a relatively small organization. It was founded
around 2000 and run by an articulate, socially aware individual, with a history of
drug use spanning thirty-five years. At the time he used methadone, however. In
terms of objectives, the organization sought to help, support and inspire active
users in their everyday lives, and promote users’ social and societal interests –
virtually a “trade union” for active users (Dagbladet 26 July, 2003). Oslo
Association of Users has never had more than fifteen to twenty paid up
members, and the leader has said that organizing users is no easy matter.
The only organization for former users among the organizations mentioned here
is Recovered Addicts’ Interest Organization (Rusmisbrukernes intresseorganisasjon – RIO), founded in 1996 as an organization for former and active
users, run by former users. It helps people find their way in the health and social
services, briefing them on their rights. Priority concerns are integration and
51
This is not an abbreviation of a longer name, though the letters LAR did stand originally
for substitution treatment (legemiddelassistert rehabilitering).
91
aftercare (Brukerforeningene 2001). The organization seeks to highlight people’s
innate resources, and has local branches in many areas of the country. The leader
is active, often in the media, and sits on the board of the National Substance
Abuse Association (Landsforbundet Mot Stoffmisbruk – LMS). All active
members of RIO have either used drugs or alcohol, but the organization does not
tolerate any consumption at all of alcohol or drugs. Relapsing members are
served a three-month quarantine notice. RIO is in that sense not an organization
for active users interested in advancing common interests.
Empowerment and Collaboration
Hence it seems that some user organizations find it difficult to sustain activity
levels, and based on the sample above, all-round organizational activity does
seem to depend on the commitment of certain prominent figures (see e.g. Jepsen
2004). In that sense, the organizations face an uphill struggle to convince
government, specialist environments and the public of their credentials.
Appearances in the media seem to be the principal way of making the
organizations and policies known. The mere fact that the media give them space
indicates their inherent newsworthiness and importance in a broader societal
framework. Media appearances do not result in greater leverage in the shorter
term, but they give users a public platform to address issues related to policy
making or treatment. Being invited to take part in a consultation on some
political or medical issue is possibly the closest the organizations gets to
wielding power in practice. But public consultations also involve specialist,
ethical and legal interests, and users may well feel disadvantaged in such
company. Whether users are empowered in practice, despite government efforts
to ease and encourage involvement in various fora, remains therefore something
of an open question (see e.g. Fosse 2001).
The extent to which the organizations themselves believe what they say matters
varies, and they also pursue different policies and speak to different audiences.
When we asked the leader of the Drugs Policy Association to put a number on
the organization’s power, he said that the value of features in press and
appearances in debates were underestimated by many people. 52 It often happens
that he gets feedback from people who say they have changed their attitudes and
views on a certain issue after they have heard his contribution. In his opinion, the
organizations enjoys a certain leverage.
The Recovered Addicts’ Interest Organization (RIO) is more likely to be invited
to sit on consultation panels than any of the other user organizations. RIO is also
the most media-savvy organization. Despite this, the organization’s leader was
52
92
Conversation with Arild Knutsen, 28 October 2004.
complaining in 2001 that their expertise and experience were not appreciated
and that “nothing happens” despite all the talk about listening to users among
politicians and professionals (Brukerforeningene 2001). Three years later, in
2004, his opinion was the same; the organization is still relatively powerless.53
The organizations are frequently used as an alibi, he believes, though that may
be changing. That aside, consulting drug users’ interest organizations on
government policy, is just “a big joke”, he says, because nobody takes their
views on board anyway.
Without visibility in the media and professional circles, pressure groups are not
likely to have much impact on politicians and the public. This is where the
Recovered Addicts’ Interest Organization (RIO) has succeeded better than the
other organizations. In addition to the leader’s media, conference and seminar
activity, other members are active in the media and the public eye. To be
considered as a serious partner by government and others, organizations need a
stable track record. Too many pressure groups have started enthusiastically but
failed to live up to expectations.
Barriers to Effective Organization
We see then how difficult it can be to run a drug user organization, whether the
substance is licit or illicit. The problems described above are, as Asmussen
(2003) writes, often caused by member instability. Taking drugs in itself is likely
to lead to unpredictability in terms of housing, friends and relations and income.
Poor physical and mental health tend to accompany life as an active user, along
with crime and longer or shorter spells behind bars. Former users are more likely
to lead stable lives, but after so many years spent among hardened drug users,
character traits like loyalty, tolerance and cooperativeness are often conspicuous
by their absence. It seems particularly hard for ex-users to trust each other, and
thinking and acting on behalf of others are alien to many (Brandsberg-Dahl
2002; Johansen 2002). Many find it difficult to cope with stress and frustration
(Watten & Waal 2001). Conflicts are hard to avoid, and common goals and
concerns easily slip out from mind. Informants we spoke with in the various
organizations confirm this general description, and how instability did indeed
paralyse activity in the short and longer term.
In light of these considerations, the relative success so far of the Recovered
Addicts’ Interest Organization (RIO) as the dominant user organization should
not surprise us. It is the most stable organization with its membership of former
users, many of whom have qualifications in social and welfare studies.
53
Conversation with Jon Storås, 24 September, 2004.
93
One important point about these pressure groups concerns the almost total lack
of cooperation. Groups are unaware of each other, and those that aren’t tend to
fall out over means and ends. When non-organized users start thinking about
rights and empowerment, they would sooner form a new organization than join
an existing one of like-minded individuals. It is therefore not only necessary to
strengthen alliances between users, authorities and professionals, but users
themselves need to learn to work together. User organizations and user
representatives are there to articulate the views of their “electorate”. Not an easy
job, considering the diversity of backgrounds and current circumstances. In
practice, people tend to identify with like-minded groups (Sigstad 2004). This
much was evident at a September 2004 consultation arranged by Oslo’s Alcohol
and Drug Addiction Service. Represented on the panel were the Danish Users’
Association (DDUU) from Copenhagen, the Recovered Addicts’ Interest
Organization (RIO) and Oslo User Association. These and other panel members,
and indeed the audience, agreed that mixing current and former users in the same
organization was fraught with difficulties. “They’ll never manage to work
together”, said one of the Danish participants by way of conclusion.
The different user organizations do, however, handle this question in different
ways. Some want to enlist and speak up for active users, others see exclusion as
the appropriate response to falling off the wagon. Oslo User Association and
Tønsberg Users’ Association both want to represent the interests of active users.
The Recovered Addicts’ Interest Organization (RIO) pursues a strict policy here:
drugs are not allowed, though the organization acknowledges the risk of
backsliding. RIO is unusual insofar as it is more akin to temperance movement
organizations, and its goals are more “politically correct” than those of the other
user organizations. As already mentioned, the RIO is more often in the media
spotlight and invited to consultations, and is also considered more dependable.
LAR-NETT is in its infancy still, too young to classify on the basis of our
criteria, but the start has been promising, and the organization could well
become one of the most powerful players.
Causes of Conflict
Interorganizational strife peaked in mid-2005 in the media. RIO was basically
lined up against all the other organizations – in other words, the argument was
between current and former users. Harm reduction is the crux; every time a new
harm reduction initiative is proclaimed, or an existing one changed, controversy
is never far away. Substitution treatment and supervised drug injecting facilities
were and remain strongly contested issues, also among the public is divided on
them as well. We would like to illustrate the situation with two practical
examples. We let media quotes describe the controversies and opinions of the
various parties.
94
Case 1
June 2005 saw the publication of a report by the Directorate for Health and
Social Affairs on substitution treatment. The report recommended among other
things making methadone and buprenorphine-based medication available to a
wider group of users (see e.g. Aftenposten 12 June, 2005). The leader of RIO
took issue with the proposal, and at a meeting with the Minister of Health called
it “pure madness to relax policy on methadone treatment…. We are speaking on
behalf of most drug users in the country” (Aftenposten 15 June, 2005).
This latter statement irritated Tønsberg Users’ Association (BFiT), who had
welcomed the Directorate’s suggestions. In his response, BFiT’s leader said,
“What is madness is that so-called user organizations can make statements like
this. The Directorate’s suggestion is brilliant, and has given lots of people fresh
hope” (Aftenposten 15 June, 2005).
Case 2
The summer of 2005 saw the first edition of “= OSLO”. Modelled on the UK’s
The Big Issue, a magazine bought and resold at 50 per cent profit by homeless
people and active drug users, this first number carried interviews with leaders of
the Recovered Addicts’ Interest Organization (RIO) and the Drugs Policy
Association (NF). There was no mistaking RIO’s opposition to injection rooms,
nor the Drugs Policy Association’s view of them a significant step in the right
direction (= OSLO No. 1, 2005). The next edition published a response under
the heading “RIO – who do you represent?”, written by a person currently
serving a sentence for drug-related offences. Reacting strongly to RIO’s stance,
he says among other things,
Those that read the article here in prison were all pretty upset by it. We draw the
conclusion that this leader of RIO lacks the insight required to lead an interest
organization for the average drug user. Leading an organization called RIO –
drug users’ organization – comes with certain responsibilities. Whoever this
organization actually represents is any one’s guess! It’s certainly not us. (Stig
Kvale, = Oslo No. 2, 2005)
In these instances it would not have been difficult to predict who said what.
Organizations of former users seldom come out in support of harm-reducing
measures, preferring instead to encourage users to quit. Organizations of active
users want to see harm-reduction measures improved and expanded to ease the
lives of current users. Which of them is “best” is impossible for us to say, but we
have seen that former users, as the most “politically correct” group, are more
likely to be consulted than the others. In that sense, we could say that real “user
95
leverage” remains an unfulfilled hope, because in reality, only people that have
stopped taking drugs are listened to.
Government and User Consultations – Expert Panels and
Action Plan for “Plata”
User participation in Norway is not restricted to the work of user organizations’
views; within a short space of time individual users, including active users, were
invited to take part in decision making of relevance to their everyday life and
future prospects. We describe below two forms of consultation, one at the
national level, the other at the local authority level, arranged in this case by
Oslo’s Alcohol and Drug Addiction Service.
Expert Panel on Drug-related Problems Under the Ministry of Social
Affairs
An expert panel was set up in 2003 by the Ministry of Social Affairs to report on
drug-related issues. Representing several sectors, including research, law
enforcement, medicine and healthcare, the panel is spearheading the ministry’s
search for new ideas to solve “old” problems. There are two users in the panel
moreover, relatively randomly selected on the basis of experience with drugs and
publicly stated views. Why user participation is considered necessary is set out
in the Government’s “Action plan to combat drug- and alcohol-related problems
2003–2005”.
Two expert panels will be appointed to advise on prevention and treatment
including harm reduction. It is important that next-of-kin and/or other carers and
former substance misusers share their knowledge with these panels.
(Regjeringens handlingsplan mot rusmiddelproblemer 2003–2005, 14–15)
The leader of the Recovered Addicts’ Interest Organization (RIO) is one of the
two users on the panel. The choice of user representatives has been criticized,
among other things because one of them is a member of one of Norway’s
foremost political families. She was allegedly chosen for speaking openly to the
media, and because her family connections and drug abuse were widely known.
In her own defence she says she only represents herself, no one else, and wants
to share her experience. She feels often misunderstood by the media, and has
chosen to lie low. As it happened, working with the rest of the panel did not
meet expectations. Neither of the user representatives felt they were taken
seriously – but used as a sort of alibi.54
54
96
Conversation with Nini Stoltenberg, 9 March and 13 September 2004; Conversation
with Jon Storås, 24 September, 2004.
This shows us how user perspectives and consulting with users on policy matters
are defined and accepted at the highest political levels, and how users themselves
benefit to all intents and purposes from a new, more socially acceptable status,
strengthening their right to be consulted. We say “to all intents and purposes”
because the experience of the two user representatives on the panel could be
framed in terms of power and control mechanisms described by Foucault and
Christie, and the fact that new concepts and good intentions do not always
translate into new practices. It also indicates a slower pace of change at the
social context level mentioned above than one often tends to believe.
User Participation in Practice – An Example from Oslo
A plan of action was launched at the end of 2002 aimed at discouraging drug
users from congregating in downtown Oslo by offering alternative sites. The
authors were five ministries, the city authorities and city police force. Drug users
used to gather in the square in front of Oslo central station, known colloquially
as “Plata”. Users were not consulted during the plan’s preparation, and none
were invited to sit on the plan’s steering committee. The plan is one of the most
significant drug-related interventions in Norway in recent years. User
participation is, however, hardly broached at all in the 38-page document.
“Hardly”, because it is mentioned once, in connection with sites where users
could conceivably gather – typically known as day shelters (væresteder);
(Tiltaksplan for alternativer... 2002).
A competence centre under the city of Oslos’ Alcohol and Drug Addiction
service published a report in 2004 entitled “Day Shelters – A Low-Threshold
Amenity in the Care and Rehabilitation of Drug Users” (Væresteder som
lavterskeltiltak i rusomsorgen). The report differentiates various approaches to
user participation.
User participation may mean taking users seriously by consulting them in all
decision making. It may mean organizing meetings with users, house meetings
where day-to-day management issues can be discussed. And it can mean
employing former users in various types of job/voluntary work/job training.
(Væresteder som lavterskeltiltak... 2004)
Insofar as no one had envisaged user participation in this light before, opinions
of users themselves were extracted from survey interviews in the evaluation of
the plan.55 In April and August of 2004, the National Institute for Alcohol and
Drug Research (SIRUS) completed six focus group interviews to elicit user
opinion of the “Plata plan”, the presence of drug users in downtown Oslo,
interaction with the police, and status in general of users who gather in the centre
55
The evaluation was conducted by SIRUS (Norwegian Institute for Alcohol and Drug
Research), and Olsen made the referenced interviews.
97
of town. More or less simultaneously with the second round of interviews, the
Alcohol and Drug Addiction Service addressed the issue themselves through a
number of user consultations. In August and September 2004, the agency held
nine user consultations at their low-threshold institutions. Users were asked what
they thought of the situation in downtown Oslo, and what was needed to ease
their daily lives (Brukerhøringer... 2004). The September consultations were
attended by two representatives from the Danish Users’ Association (DDUU).
Their stay in Oslo lasted three days, and in addition to expanding the
consultation panel, they were treated to lunch by the city and introduced to users
and staff.
Oslo council voted to spend 2 million kroner in 2005 on a new day shelter for
users, and 4 million on a building for users. According to the minutes of the
September 2004 meeting of the Plata plan steering committee, the Alcohol and
Drug Addiction service emphasized user participation for the first time in
connection with projected measures for active users (Styringsgruppa... 2004). In
a new development, in 2004, the agency posted details of user consultations and
conferences on its web pages. In the wake of these consultations, user panels
were created. They convene regularly, some as often as once every week. The
panel entrusted with planning the new user building has eight members (active
users). This group also intends to form its own organization, though why they
are not interested in joining one of the current organizations is not known.
This form of user participation and consultation lends itself to interpretation in
terms of social control (cf. Foucault and Christie). No attempt was made to
conceal the desire behind the action plan to disperse groups of drug users
congregating in the city centre (Tiltaksplan for alternativer til rusmiljøene i Oslo
sentrum 2003–2005). Opponents of the plan called efforts to disperse the group
an act of “social nuisance”, because rather than setting out to help users the idea
was to clean up public spaces. The “public” should not have to see them, and
the authorities wanted to make sure tourists didn’t see them either on
disembarking at the central train station (Dagbladet 5 June, 2004; Aftenposten 4
September, 2004). Helping to design alternative sites would encourage a sense
of ownership and make use of them a more attractive proposition. Combined
with substitution treatment for drug dependency, it would be easier to monitor
and control this segment of the population. Of course, active users may not
perceive this type of control in negative terms, since their life chances are
improving and they will benefit from a range of harm-reducing and rehabilitative
interventions.
These initiatives represent a completely new approach by the Alcohol and Drug
Addiction Service. The new user panels, in opposition to the old ones, give users
a hand in the preparation of new interventions. In this sense, user participation is
now integral to the system. The Service sees it as a key endeavour in the effort to
disseminate the user-centred approach among partners. It may also be seen as a
98
new policy on the part of the “system” when a government body sees fit to invite
organizations of active users to an official arrangement to encourage user
involvement in Norway. Something is changing in the area at the level of local
government in Oslo, it seems.
Conclusion
Several coincidental developments in the 1990s made the formation of user
organizations possible, triggered by the 1994 methadone project. Of the
organizations and associations to appear since then, those intent on promoting
the interests of current drug users and those designed to pursue concerns of
former users remain divided on policy and practice, which largely depend on
which constituency the organizations serve. The seemingly best-functioning
organization is the one for former users; at the moment it is consulted more often
than any of the others on drug policy issues.
In the recent years we have seen two forms of user consultation. One at the
national level by the use of an expert panel on drug issues, and another at local
authority level by Municipal of Oslo’s Alcohol and Drug Addiction Service.
In terms of the number of different user organizations in Norway, user opinion is
unevenly represented in consultations. Former users tend to dominate, not active
users or methadone users. Former users then determine in part how drug use and
related policies are construed. It seems as if society is not quite ready to take
active users seriously, and the views of active drug users are therefore not given
as wide a hearing as originally intended. By pursuing a policy of user
participation, society risks ending up with a control mechanism rather than a
means of empowering the people concerned. If the authorities seem ready to
listen to the views of a marginalized group and give them what they want (i.e.
more widely available methadone substitution treatment, injection rooms, day
shelters), it is easier to maintain peace and exercise control over where the group
congregates.
By and large, organizations for users in Norway are internally fragmented and
often at loggerheads with one another. There is no united front, and there is little
evidence of efforts to repair relations. On the contrary, it looks as if a new
climate will require a new user organization, instead of the established ones
adapting to new circumstances. The conflicts that separate user organizations are
serious and persistent, and the issues they pursue often reflect whether opinions
voiced in public are those of active users or former users.
Translation: Chris Saunders
99
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Skretting, Astrid & Rosenqvist, Pia (Eds.) (2006): Drugs in the Nordic and Baltic
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Nordic Council for Alcohol and Drug Research (NAD), pp. 11–42.
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Mathiensen, Thomas (1975): Løsgjengerkrigen [The vagrancy dispute]. Sosionomen,
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Regjeringens handlingsplan mot rusmiddelproblemer 2003–2005 [Government Action
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http://www.odin.no/filarkiv/161426/DAR-rusplan.pdf
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consultation – Alibi or reality?]. Tidsskrift for den norske lægeforening, No. 1: 63–64
Skretting, Astrid (1997): Evaluering av Metadonprosjektet i Oslo, Del 1. Etablering,
inntak av pasienter og forholdet til øvrige behandlingstiltak [Evaluation of Oslo’s
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September 2004.
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Drug Scene in the Centre of Oslo – A Plan of Action 2003–2005]. Oslo kommune,
Byrådsavdeling for velferd og sosiale tjenester [Oslo City Council, Department of
Welfare and Social Services]. 2002.
Watten, Reidulf G. og Helge Waal
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(2001): Avrusning: fra vilje til medisin.
gjennom en forundersøkelse av ultrarask
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http://www.rusmiddeletaten.oslo.kommune.no
102
Organisation Among Drug Users in Sweden
Leili Laanemets
The purpose of this article is to describe and discuss drug user organisation in
Sweden, a country that enforces a highly restrictive drug policy (Tops 2000).
The ultimate aim of that policy, first adopted by the national parliament in the
late 1970s and still enjoying political consensus, is to have a “drug-free society”.
Swedish drug policy is commonly described as standing on three pillars, i.e.
prevention, control and care. Care is primarily in the form of drug-free treatment,
but methadone and buprenorphine-assisted maintenance treatment is also gaining
ground (CAN 2004). The Swedish drug abuser is said to live in difficult social,
economic and material living conditions, excluded from mainstream society
(Svensson 2000).
The first wave of client movements in Sweden began to rise in the latter half of
the 1960s. Among the earliest was the National Association for Aid to People
Addictive to Drugs and Pharmaceuticals (RFHL), which also involved people
who had no personal experience of drug use. Self-help movements began to
expand and gain increasing influence in the field a couple of decades later.
However, it was not until the concept of “welfare service users” emerged on the
(social) policy agenda that the views and opinions of drug users, in their capacity
as care and service users, began to receive more serious attention in the political
and public realm.56 Service users have been officially consulted by the Swedish
Minister of Public Health and Social Services, for example, and social projects
have been set up around the country to support and promote the empowerment
and influence of drug users. In this sense the political environment for
organisation is favourable indeed.
On the other hand for drug users the heavy emphasis on the drug-free concept
means that opportunities for organisation are quite restricted, at least if the aim is
to gain official legitimacy. In principle, organisation among drug users is only
possible insofar as they are former drug users, or at the very least are committed
to quitting drugs. This means that most organisations in which users are actively
involved consist of former users. As well as working to persuade public and
political opinion, many of them serve as complements and extensions to the
official system of professional care for drug abusers. The focus of the discussion
below is on the extent that opportunities exist for organisation among drug users
in Sweden. Is this a new phenomenon? What kinds of organisations are there for
56
The question of how far the demand for participation has translated into a real influence,
is discussed in more detail in the article by Björn Johnson in this publication.
103
drug users? What forms do these organisations take and how do they relate to
state power?
In order to address these questions we need first of all to go back in time to the
mid-1960s when the drug issue first surfaced in Swedish society (Olsson 1994;
Lindgren 1993). In addition, we need to have a picture of the Swedish context:
public perceptions of drugs and drug users, the extent of drug use and the kinds
of organisation there are in the country. This article is therefore chronologically
organised and starts out from the mid-1960s. A distinction is made between three
different phases of organisation, which are the client movement, the self-help
movement and the present-day organisation of drug users. The text is based
exclusively on secondary sources, and the purpose is to provide an overview of
user involvement as far as drug users are concerned.
For the purposes of this text I use the theoretical model developed by McAdam,
McCarthy & Zald (1996). The model is structured around three factors that are
relevant to all forms of social movement and that I suggest are applicable to
Swedish organisations as well. The first of these factors is called “political
opportunity structures”, and it consists of the specific and unique context in
which the movement originates and operates. Every country has its own
historical, material, cultural and social conditions that present both obstacles to
and opportunities for organisation, that make the movement what it is and that
create the framework to which it must relate itself. The second factor consists of
the “mobilising structures” that the movement has to be able to bring together
and set in motion in order to succeed. This is about creating, steering and
organising resources in such a way that functional channels are created for the
mobilisation of people and for involving them in collective actions. Third and
finally, it is necessary to have a group of people consciously and strategically
working to organise and coordinate their views both on the environment and on
themselves in order to motivate and legitimise their collective action. This
process of “frameworking” involves constant and continuing negotiation with a
view to creating a common frame of interpretation within which to understand
and define different kinds of situations or behaviours, and it also provides an
opportunity to make adjustments to one’s own subjective identity formation. In
what follows my aim is to discuss and interpret the growth of user involvement
among drug users in Sweden against these three factors.
Public Perceptions of Drugs in Sweden
The official stance on drugs in Sweden, the aim of a “drug-free society”, is not
really open to negotiation, and certainly difficult to challenge. This is apparent if
we look back at past debates on drug policy, which have involved several
controversies for instance around methadone treatment (Johnson 2003), Subutex
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(i.e. buprenorphine) treatment and syringe exchange programmes (Svensson
1988). In international contexts, too, Sweden is firmly committed to a restrictive
stance on drug issues (Tops 2001).
In a survey of public perceptions on drugs in Swedish society, Bergmark &
Oscarsson (1988) identified four dominant ways of thinking which (borrowing a
concept from Bourdieu) they said constituted a “doxa”. Doxa refers to
fundamental aspects of society that are taken for granted, that are not and cannot
be called into question: it is the naturalised way of thinking and argumentation
concerning a certain phenomenon. In the case of drugs, the doxa is as follows.
Drugs are seen as a serious problem at the level of both society and individual,
and they are perceived as extremely dangerous. Drug abusers are victims who
are unable to quit on their own, without help. Finally, drug abuse is a condition
that requires care and treatment in order to reach the ultimate object of being
free of drugs (ibid.).
In the Swedish context, talk about drug users is always associated in one way or
another with difficulties, since all non-medical use of drugs is defined as abuse.
Drug use is criminalised and the police have the right to apprehend suspected
offenders for urine and blood tests in order to establish whether or not they have
in fact used drugs. The possession of drugs for personal use is a crime that
carries a prison sentence of up to six months. According to the Swedish justice
system, then, a person can be a drug user only if the substance is prescribed by a
medical doctor, such as methadone or buprenorphine for maintenance treatment.
Everything else is regarded as drug abuse.
Against the background of the above, one might argue that the mobilising
structures or political opportunities for people using non-prescribed drugs to ally
together, to organise themselves around drug issues and to gain formal
recognition and legitimacy for this organisation, are fairly slim.
Statistics on the Number of Drug Abusers
Sweden has conducted representative surveys of drug use among schoolchildren
aged 15 every year since 1971. Based on samples of around 5,000 and
questionnaires with virtually identical items year on year, these surveys show
that the proportion of schoolchildren saying had tried drugs peaked in the early
1970s (14–16 per cent). The figure then dropped in the 1980s down to 3–4 per
cent, only to rise again in the 1990s. In 2004 the proportion increased to around
7 per cent. By far the most common substance used was cannabis (CAN 2004).
There have also been three major national case-finding studies to assess the
prevalence of heavy abuse. Heavy abuse is defined in these surveys as consisting
of all injecting drug abuse during the past 12 months or daily or almost daily
105
drug use during the previous month. In the first study in 1979, the number of
heavy abusers was estimated at 15,000; by 1992 the figure was up to 19,000 and
in the latest study in 1998 an estimated 26,000. Both the mean age of abusers
and the proportion of abusers who had been on drugs for more than ten years
have increased over these 20 years. In 1979, the mean age of drug abusers was
25 years and 19 per cent had been doing drugs for more than ten years, whereas
in the latest measurement in 1998 the mean age had gone up to 35 years and over
one-half had a history of drug abuse that went back more than ten years. On the
whole then, drug abusers have become older, but new users are also being
recruited into this group (CAN 2004).
In the 1960s the use of opiates was in the form of raw opium. In the 1970s that
was gradually replaced first by free-base morphine and then by heroin, which
was injected. Following low levels of new recruitment in the 1980s, heroin has
gained increasing prominence among heavy drug abusers in the 1990s. In the
first survey in 1979, 15 per cent were thought to be predominantly heroin users,
by 1998 the figure was up to 28 per cent. Drug-related mortality increased
sharply during the second half of the 1990s, and in 2001 the number of deaths
stood at 336, most of who were men (CAN 2004).
Voluntary Organisations and Their Relation to the State
The national context can be seen as highly significant both to the emergence and
to the development of social movements (McAdam, McCarthy & Zald 1996).
Furthermore, certain periods of time are conducive to the formation of certain
types of social movement, with the national context forcing other movements
into the same format. In the Swedish case a key distinctive characteristic has
been the prominent role played by the philanthropic movements of the late 19th
century as well as the major popular movements – the labour movement,
temperance movements, the universal suffrage movement and women’s
movement – not only in Swedish society, but they also came to have a very
prominent role in the welfare state project.
The active policy of state intervention that began to gather momentum with the
building of the “people’s home” (folkhemmet) in the 1930s was based on a
heavily centralised and hierarchic system of state development. In this society
that was organised through and through, popular movements (or “voluntary
organisations”, as they became generically known) occupied a central position.
With the close relationship of collaboration and mutual dependence between the
state apparatus and voluntary organisations, the Swedish corporatist model
allowed for any new, progressive ideas quickly to be picked up, revamped and
adapted for application when the initiative came from above (Meeuwisse &
Sunesson 1998). Over time, voluntary organisations have taken on various
106
different roles as instigators of new ideas, care and service providers and opinion
leaders, and for all this they can receive funding from both central and local
government.
Meeuwisse and Sunesson (1998) use the term “co-opting” to highlight the
importance of collaboration between voluntary organisations and the state
apparatus. This, they say, is a relationship where the organisations assume
responsibility for the decisions made or for the implementation of those
decisions. One way of doing this is to offer seats to voluntary organisations on
various decision-making bodies, or to provide public funding for operations that
are particularly important for the organisation, but possibly for the authorities as
well. This serves to constrain the organisations’ freedom of movement, since in
return they are expected to show loyalty in their decision-making. On the other
hand, given the collaboration they have with the state apparatus, voluntary
organisations will expect that the legitimacy and continuity of their operation is
guaranteed.
There is some debate and discussion surrounding the concept of voluntary
organisations, but it still remains the most commonly used in Sweden for
purposes of describing organisations that work in the middle ground between the
official state sector and the private, informal sector. Other concepts that appear
in this context include non-governmental, civic, and ideological organisations; a
more recent arrival is the concept of user organisation. Voluntary organisations
have the following distinctive characteristics: They must be formalised in one
way or another and have a board and a general assembly for members; they must
be “private” in the sense of being independent of the public sector and
ideological in the sense that they are not driven by the purpose of generating a
profit for the board or the membership; they must be autonomous and selfgoverning and have control over their own activities; the board must not be
appointed by either local authorities, the state or private business companies.
Furthermore, the operation of voluntary organisations must be based upon
ideological contributions in the shape of unpaid labour or gifts (see e.g.
Hammare & Stenbacka 2003).
Voluntary organisations comprise a wide range of movements. One line of
distinction can be drawn on the basis of the leading principle of operation, i.e.
between “I-for-you organisations” and “we-for-us organisations”. Meeuwisse
and Sunesson (1998) emphasise that most organisations are hybrids and cut
across different areas of activity, but nonetheless accept that this distinction can
be useful. This provides the basis for the distinction between philanthropic
movements in which people pool their resources to help and represent others and
movements in which people who share the same problems get together in order
to defend and promote their own interests.
107
As far as intoxicating substances (read: alcohol) are concerned, virtually all
philanthropic and popular movements since the early 19th century have been
concerned to promote either reduced alcohol consumption or total abstinence.
Another issue high on the agenda of these early voluntary organisations was to
get the state to assume responsibility for the harm caused by alcohol at the
individual and the societal level. The first care homes for people with alcohol
problems were set up by voluntary organisations in close collaboration with the
temperance movement. The results, however, were far from satisfactory, and it
was not long before the calls for involuntary treatment started, which since then
has become an integral part of the Swedish treatment system for substance
abusers (Blomqvist 1998). The Swedish corporatist model is heavily focused on
the care of alcoholics, and more recently on the care of substance abusers in
general. Stenius (1999) describes care as a common concern, thus emphasising
the fluidity of the boundary lines between the public, voluntary and private
sectors.
The Drug Issue Enters the Scene
It was 1968 and for us, young representatives of what was to become known as
the psychedelic youth revolt, it was a matter of having your documents all in
order and keeping your pockets empty of hashis, marijuana, tin foil, chillum
pipes, pipe cleaners and other such stuff. Otherwise you knew you were looking
at being questioned and arrested, spending long dreary hours in a police cell,
going to trial and being fined or even other worse hassle by the establishment
and its “pigs”. As far as we were concerned this was war in which the police
represented the hostile force. A force that didn’t have a clue about new music,
new hair length, new clothes, new drugs, new forms of socialising, new freedom,
new experiences, new consciousness … Instead, it defended the established and
the recognized; the bourgeois lifestyle, indifference, suspicion, hostility towards
foreigners, dual morality, dance music, alcohol. (Lindgren 1993, 17).
As in other western countries, the established system in Sweden came under
heavy criticism and attack during the 1960s. The wave of dissent found various
expressions from spontaneous protests and demonstrations of different,
alternative ways of life (e.g. the hippie movement) through to more organised
extra-parliamentary activities and movements (various left-wing movements,
women’s movements). These ”new” social movements, largely driven and
dominated by young people, differed significantly from ordinary institutionalised
movements. They took up position outside the established and traditional social
order and the “modern project” (Eyerman & Jamison 1991, 23).
It was in this politicized social climate that the drug issue emerged more
prominently on the political and public agenda. Drug use was not in fact a new
phenomenon in Sweden, but central nervous system stimulating substances had
been used quite widely ever since the Second World War, and particularly in the
108
late 1950s.57 However, this use of amphetamines was not labelled as “abuse”, but
it was legally and legitimately administered through the system of medical
practice. It seems that the concept of drug addiction was reserved mainly for
barbiturate and opiate users (Olsson 1994). Hardly any treatment was available,
and the problem would be dealt with individually between patient and private
physician. In the 1950s and 1960s, a common method was to write out a
prescription for the substance in question (Olsson 1994).
Drug abuse began to increase in the latter half of the 1960s and indeed this is
often described as the period when the modern phenomenon of drug abuse
emerged and became established. Estimates based on a study in Stockholm at
this time put the number of heavy drug abusers in Sweden in 1967 at around
6,000 (CAN 2004; Olsson 1997). Drugs soon became regarded as a social
problem that it was thought would cause the ruin and destruction of the country’s
youth. Drug use came to stand for asocial, damaging, risk, and in many ways
dangerous behaviour for Swedish society, providing further reason to define the
“problem” (drug use) as a legal issue. The tone of debate was highly pitched and
there were growing fears of the other and the unknown. Drug addicts were
portrayed as enemies of society. The “drug problem” became a useful issue for
purposes of diverting the attentions of the mass media and soaking up some of
the other current political and social tensions and conflicts (Lindgren 1993).
The First Phase: The Client Movement and the RFHL
The first user organisation in Sweden was the National Association for Aid to
People Addictive to Drugs and Pharmaceuticals (Riksförbundet för hjälp åt
läkemedelsmissbrukare, RFHL), which was later to change its name. Launched
in 1965, the RFHL was the first among what were to become known as Rassociations, an umbrella concept for the wave of client movements that
developed in Sweden that in those days was enjoying strong economic growth
and that had large youth cohorts. The Social Democrats had been in power for
some time and the welfare state project was in full swing.
The need for this grass-roots intervention grew out of a sense of discontentment
with the way that society dealt with social policy issues such as drug use,
criminal care and mental health care. The movements were inspired by public
discussions and debates between professional avant-gardists within the care
sector and the judicial system, intellectuals who took an interest in social and
criminal policy, and people who had personal experiences of psychiatric care or
who had been hooked on drugs or alcohol and/or who had been to prison.
57
According to Olsson (1994), three per cent of the adult population in Sweden in 1942/43
used amphetamines. Among them 3,000 were using the drug at levels that today would
warrant the description of “heavy abuse”.
109
Ordinary, mainstream society was criticised for putting people under so much
pressure and for causing so much exclusion; the aim was to gain equality and to
show solidarity with those who had been driven out and excluded. Sven-Åke
Lindgren (1993), former Chair of the RFHL, says that the movements were
motivated in part by aspirations to break the power exercised by the state and
experts over ordinary people; in part by the ambition to do away with repressive
institutions such as mental hospitals and prisons; and in part by the perceived
need to create an alternative force that would halt the tendency towards the
psychologisation and individualisation of problems. As he put it: the aim was to
get away from the state, from the experts, from institutions and away from the
soul. The five R-associations58 together published a magazine called
“Pockettidningen R” (the Pocket magazine R) in order to give a voice to the
“care-stricken”, i.e. clients, patients and prisoners. The magazine was to become
a major representative of new journalism, offering critical analysis of society and
its institutions. In the mid-1970s, Pockettidningen R had some 17,000
subscribers, with the same number of copies sold through newsagents. These
were huge figures for that time, and the magazine became a major influence
indeed (Adamson et al. 2004).
The original impetus for the foundation of the RFHL was provided by a series of
debates where Swedish society came under heavy criticism by Frank Hirschfeldt
(later the founder and chairman) and others for the way it dealt with the drug
issue. Hirschfeldt was keen to emphasise the humanitarian and social-medical
aspects, insisting that the problem could not be resolved simply by means of
legislation and increased police intervention. The organisation was soon able to
set up an office in a condemned building in the centre of Stockholm. The rent
was initially covered by the social welfare department, but within six months it
was receiving funds from several other sources as well, including the Christian
temperance movement (De kristna samfundens nykterhetsrörelse), the Swedish
Save the Children Association (Rädda barnen), the National Board of Health and
Welfare, and the Ministry of Health and Social Affairs (Adamson et al. 2004).
The office had a staff of three who ran an open house for drug users. Predictably,
the early stages of the operation were less than convincing, and it often
descended into chaos and violence as drug users took over the premises,
threatening to turn them into “drug-user quarters” (Sannegård 2004).
58
Apart from the RFHL, there was the National Society for the Humanisation of Prisons
(Riksförbundet för Kriminalvårdens humanisering, KRUM), which was founded in
1966. The National Organisation for Mental Health (Riksorganisationen för mental
hälsa), later renamed as the National Association for Social and Mental Health
(Riksförbundet för social och mental hälsa, RSMH). Finally, the National Association
for People with Alcohol Problems (Alkoholproblematikers riksorganisation, ALRO)
was established in 1974. Each of the R-associations issued their own magazines for
members, and in 1970 they joined forces to launch the Pocket magazine R.
110
In Sweden, the drug problem was primarily dealt with in the field of psychiatry,
and the RFHL also took a critical stance on the care provided for alcoholics,
which was regarded as inhuman and repressive. The aim was to find democratic
and humane alternatives for dealing with questions of exclusion and drug abuse.
In general there was a strong undercurrent of anti-authoritarianism, and a strong
urge to introduce and test new methods, including milieu therapy, prison-visiting
groups and other ways of establishing closer links between ordinary citizens and
“social outcasts” (Nordegren 2004, 128). The object was to re-integrate drug
abusers into society.
The first treatment collective based on milieu therapy was set up in 1968, and
within the space of a few years the number of such units had risen to around 25,
with a total of almost 100 client places (Adamson 2004, 151). In most of these
collectives, staff included both former addicts and others. Thomas Nordegren
(2004), the then secretary for the association, has described some of the
difficulties that were caused by the collision of former addicts’ and other
people’s very different life experiences. He says the unlikely combination gave
rise to organisational vulnerability as the “most downtrodden and criminal”
members quickly moved into dominant positions within the organisation and
took advantage, ”disappearing with the cash” (ibid., 139).
In 1965–1967, an experiment was conducted with the legal prescription of drugs
under authorisation by the Swedish Medical Agency. The RFHL was one of the
many advocates of this project, which at one point was moved to its premises.
Initially the project involved just below a dozen or so doctors, but in the end
there remained just the one, Dr Åhström, who could not singlehandedly cope
with the constant flux of drug addicts. One of the first persons employed at the
RFHL, Wille Sannegård (2004), has described how “some of the patients were
skid-row addicts, others were intoxicated, paranoid or outright aggressive, and
others still were decent, respectable citizens who simply wanted to have their
prescription” (ibid., 111). In due course the RFHL decided to withdraw its
support, and the project was prematurely terminated. In the drug policy debate,
this project has since served as a warning example of the catastrophic
consequences of the legal prescription of drugs (Tops 2000).
At the same time as the RFHL continued with its practical efforts in care and
treatment, setting up family collectives and launching counselling programmes
and contact centres, it also set about lobbying public and political opinion. The
aim was to get people to understand the conditions in which drug addicts lived,
to demonstrate the impacts of exclusion, unemployment and the way that society
dealt with drugs and the consequences it had on drug users. The problem of drug
abuse was seen and portrayed first and foremost as a political problem, and the
association took a critical view on what is regarded as a tendency of
individualisation within the public system of care, i.e. the tendency to focus on
111
the individual and to ignore the social and political aspects. Quitting drugs was
regarded as a personal political statement (Stenius 1999).
One key issue that was raised at a very early stage within the RFHL was the
wholesale prescription of medical drugs, both in prisons, in mental health care
and indeed in the population at large. The organisation went so far as to file a
complaint with the state prosecutor against all 600 psychiatrists in the country,
claiming that they were handing out prescriptions far too liberally (Adamson
2004, 149). The purpose was to draw attention to the economic interests of the
pharmaceuticals industry: parallels were drawn between the legal prescription of
drugs and illegal drug abuse, and it was argued that legal drug use was also
causing passivity, dependence and social isolation. The only difference was that
the drug dealers in this case were the state and pharmaceutical companies
(Nordegren 2004).
The organisation continued to grow and become more formalised. A national
board was appointed and independent local associations created, with a network
of contact persons set up to cover smaller localities. Both the national board and
the boards of local associations were made up of former addicts, public
authorities and radical contributors to public debate (Nordegren 2004). It also
launched a member magazine, which had a circulation of a couple of thousand
copies. As well as receiving subsidies from central and local government and
other sources, the RFHL now gained public recognition and was consulted in an
expert capacity for various state surveys, for example by the National Committee
for the Treatment of Drug Addicts (Narkomanvårdskommittén) in 1969. In this
way it gained an increasing say over matters of state policy.
Striking a Balance Between Criticism and Search for
Legitimacy
The R-associations brought together large numbers of people under their
umbrella. They were an integral part of the wave of radicalism that swept
through Sweden in the 1960s and 1970s, driven by people who took a critical
view on the established and the traditional and who were committed to finding
alternatives. The strength of the movement derived from its broad composition,
involving as it did both intellectual academics and people with personal
experience of the downside of the welfare state as patients, clients or prisoners.
This immediate contact between personal experience and the theoretical,
analytical and verbal skills of the intellectuals involved in the movement as well
as contacts within the mass media and the state apparatus provided a solid
sounding board for social criticism and at the same time afforded legitimacy to
the organisations.
112
For both of these parties, the movements opened up opportunities and even
career paths, giving individuals a chance to rethink and reorganise their own
experiences and to work out new understandings and meanings for those
experiences. This, according to Asmussen & Jöhncke (2004), can even lead to a
completely new image of oneself, one’s situation or one’s own subjective
identity, as described among others by Strömstedt (2004). He provides an
account of how he “learned he was oppressed” in prison and says that this
awareness was what gave him the strength to change his life. The organisations
created various meeting-places where clients, patients and inmates were able to
get in touch with new social groups and in this way gain direct access to the
public arena in society. The intellectuals, for their part, gained access to
materials that could be turned into plays, documentaries, feature films, books,
articles and television and radio programmes.
This “double competence” was hugely influential not only in opinion formation,
but also in the development of new treatment alternatives whereby the treatment
of drug addicts emerged as a whole new area in Swedish society. In its capacity
as representative of drug abusers, the RFHL was also in the position both to
legitimise its criticism of the treatment system and to carve out a role for itself as
an expert in the care of drug addicts. The 1970s also saw a marked increase in
drug treatment activities coordinated and administered by foundations and
associations (Stenius 1999). This provides an example of how the organisation
sells and uses its knowledge for purposes of securing its own survival.
The experiment with legal drug prescription in the late 1960s was taken to
constitute a serious threat to the RFHL’s legitimacy, and many took the view that
for reasons of self-preservation the organisation should dissociate itself from the
project. Activists involved in the organisation at this time have argued that the
experiment and the fact that it was so closely linked to the RFHL burdened the
organisation for a long time, for it meant that it became labelled as an advocate
of a drug liberal policy – which in the Swedish context is not good news. They
say that the efforts by the RFHL to take critical distance from methadone
treatment was effectively an effort to erase that label (Adamson et al. 2004). At
the same time, the adoption of this stance meant that the RFHL landed on the
same side of the drug policy debate as its main adversary, the Swedish National
Association for a Drug-free Society (Riksförbundet för ett narkotikafritt
samhälle, RNS). It was not until the late 1980s that the organisation revised its
position and expressed its support for methadone substitution treatment.
The anti-methadone stance adopted by the RFHL serves as an example of how
the organisation through its involvement in the legal prescription project
challenged the Swedish doxa on a drug-free society. This meant that if the
organisation was to gain legitimacy in the first place, it would have to dissociate
itself categorically from everything that was linked to harm reduction – and in
this, the focus on the drug-free concept was crucial.
113
Apart from methadone, another major issue of contention in the Swedish debate
on social and drug policy was the involuntary treatment of abusers, which
remained firmly on the agenda from the late 1960s through to 1982 when
legislation was adopted on involuntary treatment in certain cases. During this
period the issue was addressed in several state surveys, but none of them
managed to resolve the problem. The RFHL made clear its stance on involuntary
treatment from very early on as it advocated the development of voluntary care
that was based on the needs and wishes of drug addicts themselves while still
aimed at the ultimate goal of freedom from drugs. The organisation also invested
great effort in shaping public opinion against the toughening climate in society
against drug abusers, engaging in debates and conducting surveys and providing
its expert opinions to emphasise the importance of solidarity with drug abusers.
The RFHL was at its prime in the late 1970s, and then began to slip down a
slope of decline as the wave of radicalism ebbed away. In the latter half of the
1980s, its operations began to wind down and several treatment collectives were
closed in the absence of a sufficient number of clients. In its search for
legitimacy, the RFHL had to constantly work on activities that attracted drug
users, such as its contact centres and alternative forms of treatment, but at the
same time it had to distance itself from its client’s way of life. This balancing act
between representation and distanciation was occasionally described as difficult,
particularly during periods when the repressive forces gathered momentum
(Wallbom 2004, 161).
The Second Phase: The Self-help Movement
Even though self-help movements are not primarily concerned to change or
shape the social conditions that impact the life of drug addicts, for example, they
still are a typical example of voluntary organisations of the “we-for-us” type
(Meeuwisse & Sunesson 1998). In contrast to client movements that also involve
people with no personal experience of drug use, the self-help movement is
confined to members who have first-hand experience of drugs or who are
indirectly involved as “co-dependents”. The first self-help groups in Sweden
were active initially in the alcohol field.59 The first Narcotics Anonymous group
(Anonyma Narkomaner, NA) started in 1987.
NA is totally independent in its operation from both central and local
government. As the name implies, participation is based on anonymity, and the
meetings are structured around the same 12 steps that are familiar from the
Minnesota movement. The starting-point is provided by each user’s own
personal experiences and the need to share those experiences with other people
59
Länkarna, a Swedish version of Alcoholics Anonymous, was founded in the mid-1940s.
The first AA group was launched in the mid-1950s.
114
who share the same kind of situation. The association accepts no subsidies, it
provides no consultancy or expertise, and NA members do not participate in any
organized collaboration with public authorities on a structural level. In addition
to self-help groups, NA activities may include telephone helplines and
sponsorships, with participants who have been off drugs for longer periods
supporting those who have only just started. These members may also contact
local alcohol clinics, hospitals, treatment homes, prisons and social welfare
departments and offer their services as a rehabilitated abuser and share their
experience of how they achieved abstinence.
Local NA groups are divided into circles, which in turn make up geographical
regions in which each local circle has its own representative. There is a national
council and each year a national service conference is held. Among the council’s
duties are to ensure that the local groups adhere to the tradition of 12 steps and
that the decisions taken at the service conference are put into effect (Hammare &
Stenbacka 2003).
The self-help movement has grown enormously and spread all around the world.
The reason for its success is usually thought to lie in its independence from the
surrounding world, with the autonomous and self-directed group at its heart.
Helmersson Bergmark (1998), however, takes a critical view of this assumption
and maintains that it is its form that makes the movement a victim of its external
circumstances. By way of an example, she describes the development of selfhelp groups in Sweden and shows that their considerable growth and expansion
ties in closely with the launch of the Minnesota model in the Swedish system of
abuser care. Even though the AA has been active in Sweden since the
mid-1950s, the movement’s breakthrough only came with the need for aftercare
for all those abusers who had been through the Minnesota programme. The
number of self-help groups then increased several times over a period of ten
years, from the mid-1980s to the 1990s.
Unlike the RFHL which placed drug use in a social policy or societal context,
the self-help movement and NA focus on the phenomenon of “abuse” and the
abuser. The individual is thus isolated from the social context, and subjective
identity formation starts out from and builds upon drug abuse. Through the 12step programme the abuser gains access to a comprehensive system of treatments
and explanations, which provides the framework for interpreting and
understanding one’s life. At the centre of it all is the process of identity
formation. Steffen (1996) emphasises the total inclusiveness of the twelve-step
model, suggesting that the programmes can only be viewed and assessed as a
whole, where truth is juxtaposed with lies. The programme, she says, “offers
members a new social identity from the vantage-point of a total experience of
reality” (ibid., 16).
115
This focus on drug abuse is also reflected in the form of organisation. The main
core consists of group meetings where the anonymous participants discuss the
consequences of abuse against the background of their own personal life
situation; they then split up and return to their everyday lives. This kind of
community that is based on an exercise of individual reflexivity regardless of
social position, is very much in line with the modern project of self-realization
and is also thought to contribute to the popularity of the self-help movement
(Mäkelä in Helmersson Bergmark 1998). In general both the self-help
movement’s ideology and its concept apparatus have very much shaped and
influenced the everyday terminology about questions of abuse.
Substance Abuser Care in Sweden is Cut Back and
Restructured
Both the RFHL and the NA took shape in an environment of ever-expanding
efforts to combat and contain substance abuse, whether by means of prevention,
care and treatment or control. The care of substance abusers and drug policy
have enjoyed high priority and attracted much debate and discussion in Swedish
society. The point of culmination was reached in the mid-1980s with “Offensive
Drug Abuse Care”, a government programme aimed at containing the spread of
HIV in which drug addicts were to be picked up from the streets and prisons and
other everyday environments and encouraged to receive care (Stenius 1999).
Methadone substitution therapy was reluctantly accepted, and the maximum
number of patients was doubled from 150 to 300 in 1988 (Johnson 2003). Needle
and syringe exchange programmes were also launched in some areas, despite
fierce objection and protests. The Swedish system of institutional care for
substance abusers, which covers both alcoholics and drug abusers, was at its
prime in the late 1980s, when the number of substance abusers receiving care on
any one day peaked at around 5,000. It is estimated that in the 1970s and 1980s,
the annual number of people admitted for some type of institutional treatment
was between 14,000 and 18,000 (Blomqvist 1998). These figures were based on
the number of institutional places; no data are available on the number of
contacts in community care.
The restructuration of the Swedish welfare state, and by the same token the
system of abuser care, got under way in the late 1980s. Market-oriented models
were introduced and tested, the heavily centralised state system began to take a
more backseat role, central government transfers to substance abuser care were
discontinued, and the provision of abuser care was increasingly delegated to
local municipalities. Long-term institutional treatment decreased, whereas
Minnesota programmes increased sharply so that by the end of the 1980s they
accounted for almost 25 per cent of all institutional places (Stenius 1999). The
crisis in central government finances in the early 1990s led to cutbacks in public
116
expenditure, which had the effect of dramatically reducing the provision of
institutional care, increasing the number of private and voluntary organisations
in the field, intensifying competition between different forms of care, and
increasing the number of abusers whose options were limited to community care.
According to the National Board of Health and Welfare (2005), the total costs of
substance abuser care in Sweden have been cut by 20 per cent since 1995, in
spite of the sharp increase in the demand for detoxification beds, treatments,
psychiatric care and aftercare. The situation has been improving in the past few
years, though. Calculations by the National Board of Health and Welfare show
that within social services, substance abuser care had daily contact with more
than 21,000 alcohol and drug abusers. The vast majority of these contacts had to
do with community care, but also with housing benefits and institutional
treatment. The number of people receiving institutional care on any one day
totalled 3,600 (ibid.). As for drug abusers, it is estimated that among the 26,000
people identified in the 1998 census, some 10,000 were in contact with social
welfare services and 13,000 with medical health care (ibid.).
Apart from the earlier drive to cut back on service provision, another distinctive
characteristic of the Swedish system of substance abuser care is the wide range
of treatments and models it supports. The medical component has gained
increasing prominence, both as a result of the illness model and the growth of
substitution therapy using methadone and buprenorphine. Restrictions remain in
place on the prescription of methadone, but the indications and rules have
nonetheless been eased. Furthermore, the ceiling for the maximum total number
of patients has now been removed. On the other hand, rules for the prescription
of buprenorphine have been tightened, as only doctors working within the
addiction field are now allowed to issue prescriptions (National Board of Health
and Welfare 2004). There are currently some 2,000 people in Sweden today who
are on methadone or buprenorphine substitution therapy (oral source). There are
two cities that run needle exchange programmes, i.e. Malmö and Lund, which
together have some 1,500 patients (pamphlet 2004, from needle and syringe
exchange programme).
The implications for the individual abuser are twofold: on the one hand it has
become harder to gain access to care, on the other hand it has meant they have
had to assume greater personal responsibility for their situation. A number of
reports have come out talking about a Black Peter game where the authorities are
trying in various ways to avoid the heavy costs of care provision and to promote
more open and less expensive forms of treatment. The deregulation of the
housing market has made it much harder for addicts to find a place to live, which
has driven up the number of homeless people. All in all, there has been a marked
deterioration in the social and economic circumstances for large numbers of
heavy drug abusers, adding further to their marginalisation. Over the years a
large proportion of them have also taken part in various treatment programmes
117
and are now showing signs of “treatment fatigue” (Kristiansen & Svensson
2004; Lander et al. 2002).
The Third Phase: The State Withdraws
At the same time as the state has withdrawn into a more backseat role, voluntary
organisations have taken on an increasingly prominent role, both within the field
of substance abuse and in other welfare sectors. The political rhetoric describes
voluntary organisations as playing a key role in “deepening welfare”; they
complement the official, public system and have a special competence that is
clearly distinct from that of professionals. Indeed, the government has created a
new policy field dedicated specifically to popular movements. User involvement
is also a feature of several other state measures, the aim being to get welfare
service users take a more active role in their own care. This is done by such
means as study circles, user councils, user panels and conferences in order to
give a voice to users (see e.g. Prinz 2003). It is noteworthy that several different
types of organisations are active in the drug field.
The RFHL, the oldest of these organisations, operates on both the central and
local level. For a number of years now its membership has been around 3,000,
some 2,000 of whom have personal experience of drugs and/or addictions to
medicinal substances (Meeuwisse & Sunesson 1998). Most of its funding comes
in the form of government subsidies, less than one-quarter comes from the sale
of services. Around 60 per cent of the RFHL’s activities consist of support and
treatment, 30 per cent of work to lobby public and political opinion and
prevention, and the rest of counselling and education. The association also
publishes a magazine called “Oberoende”, which features critical commentaries
on the adverse effects to clients of cutbacks in care provision. The RFHL has
also been involved in launching “Basta”, a work cooperative that provides
rehabilitation but also runs businesses part-owned by former abusers.
Measured in terms of the total numbers involved, the biggest movement of all is
without doubt the self-help movement, as represented by the AA60 and the NA.
According to the AA’s own estimates, it had in 1998 some 500 self-help groups
that involved some 10,000 people (Hammare & Stenbacka 2003). The NA says
on its website that it has just over 200 self-help groups.
There are also many other voluntary organisations in Sweden today that have
been set up and that are run by former drug addicts and that are partly funded
from central or local government sources. These include Convictus, Basta,
60
Drug users are also welcome to attend AA meetings. There is some oral evidence that
people on medically-assisted substitution therapy (methadone, Subutex) prefer to go to
AA meetings instead of NA meetings.
118
Dianova and KRIS (Criminals’ Return Into Society / Kriminellas revansch i
samhället). The purpose of these organisations is to provide peer support, which
may be in the form of cafés, social activities, alternative housing, abuser
treatment and work cooperatives. Indeed, it is a broad spectrum of activities that
are covered. Some of these organisations’ activities have been upgraded into
“services” that are sold as alternatives to those offered by social welfare
services. Some organisations, including the RFHL, Basta and Dianova, have
pooled their resources in a centre known as “Rainbow Sweden”. Yet another
type of association is the Swedish Users Union (Svenska Brukarföreningen,
SBF), which differs from the rest of the field by explicitly supporting a drug
policy based on “harm reduction”. The text below offers a brief description of
two of these organisations, i.e. KRIS and the Swedish Users Union. The choice
of these two cases is based on their both being organisations for drug users and
actively involved in the social debate, but at the same time they occupy opposite
ideological poles. While the Swedish Users Union also represents active drug
abusers, KRIS is a firm advocate of the Swedish drug policy ideal of total
abstinence. As for their relationship to the authorities and other actors in the
field, the Swedish Users Union takes a more critical stance than KRIS against
official drug policy. It is particularly unhappy with care and treatment available
for opiate addicts.
Criminals’ Return Into Society / Kriminellas Revansch i Samhället
(KRIS)
KRIS was founded in Stockholm in the autumn of 1997 by four people with long
histories of crime and substance abuse. They wanted to set up a peer association
whose members would together provide a supportive network for others who
wanted to leave their former life behind. KRIS was soon in the public eye
following a TV documentary which showed a group of members standing
outside the gates of a prison, waiting for a prisoner who was going to be
released. This standing and waiting outside prisons became one of the
association’s hallmarks, a manifestation of its ideological premise that quitting
drugs and crime requires not only commitment, but also social support and a
drug-free community. Many of the association’s members are also active in the
NA and the AA, and indeed complete abstinence and freedom from drugs are
among their main tenets. KRIS is strictly opposed to needle and syringe
exchange as well as maintenance treatment with methadone or Subutex.
KRIS consists of a national association and a number independent local
departments (in autumn 2005 there were 28 such departments). It receives its
funding from central and local government project appropriations, private
business companies and the sale of services. The larger local departments
usually have a few employees, whose wages are paid partly from central
119
government and municipal subsidies. In addition, there is a board and a
membership who work on a voluntary and ideological basis (BRÅ 2003).
According to the association’s website, it has 5,300 paying members who have
personal experience of drug abuse and crime.
The association mainly provides a source of peer support. Each local department
has its own premises and meeting place for members, which will typically
include a café, a pool table, magazines, games, and TV. The main focus is on
social activities, excursions, sports, training sessions, football, and cinema, but
there are also study circles for example on meeting techniques. KRIS also
publishes its own member magazine, called “The Way Out” (”Vägen ut”).
Furthermore, KRIS organises visits to prisons where members take charge of
discussion groups, motivate inmates and hand out information about the
association. This activity is supported by funds from criminal care services. In
addition, KRIS runs various information campaigns, and its members frequently
visit schools to give lectures.
Based on its studies of KRIS, the Swedish National Council for Crime
Prevention (BRÅ 2003) says that there is an element tension between the
association’s professional members and its more ideologically minded members.
The introduction of new services has created competition and disagreement, and
attention is drawn to the difficulties of maintaining a balance between
professional commitments and the simultaneous provision of peer support.
According to BRÅ, the steady growth of professional ambitions has happened at
the expense of social activities and community. It also make the critical point
that the association’s insistence on absolute freedom from drugs and strict
adherence to the law may lead to the exclusion of large numbers of members.
Svenska Brukarföreningen / The Swedish Users Union61
Svenska Brukarföreningen, the Swedish Users Union was founded in October
2002 by people in medically-assisted maintenance treatment. The full name of
the association is “The Swedish Users Union – help for opiate users and people
who have or need methadone or Subutex”. The following text is based on the
association’s website and newsletters.62
The association’s aim is to promote and defend the interests of “heroin addicts”,
both within the field of substance abuse care and elsewhere in society. It is
committed to changing Swedish drug policy so that it is based on the principle of
harm reduction. The Swedish Users Union is in favour of needle and syringe
61
62
The Swedish Users Union is discussed in more detail in the article by Jessica Palm in
this publication.
Www.brukarforeningen.com, accessed 17 December 2005
120
exchange, which it considers important purely for reasons of health promotion.
In its programme the association compares drug addiction to other diseases and
says that treatment must be based upon “science and proven experience”: no
professional, it continues, must be allowed to give preference to a certain
treatment on ideological grounds. Furthermore, the Swedish Users Union wants
to see waiting lists for care and treatment abandoned and replaced by a system
which guarantees access to substitution therapy within 72 hours or to drug-free
treatment within 14 days. Patients’ rights to maintenance treatment must also be
guaranteed.
The Swedish Users Union says it is still in the process of building up its
operation. Initially the association had access to a room at RFHL’s offices, but it
has now premises of its own. The association runs information campaigns to
persuade public opinion, and it has helped to start up a user council at two
addiction clinics in Stockholm. It also offers help to members in their contacts
with the authorities. According to the same newsletter, the association has
helped almost 100 members to file documents with the National Board of Health
and Welfare, the Patients’ Committee and/or the Committee on Medical
Responsibility. The issues addressed have ranged from the suspension of social
benefits to cases where patients have been excluded from treatment programmes.
The association is organised into one national department and six local
departments. There is also an association for next of kin. In 2004 the association
had a membership of almost 800. The Swedish Users Union is also a member of
the international network for methadone patients (NAMA), and it works closely
with its sister organisations in Copenhagen and Oslo. The Swedish Users Union
is also an expert association whose opinion is consulted in state surveys.
Discussion
Ever since the mid-1960s when the drug issue began to emerge in Sweden, drug
users have taken an active involvement in various kinds of organisations in order
to take advantage of other users’ experiences and to share their own views. The
Swedish “doxa”, which looks upon drugs as a serious social and individual
problem, which regards drug abuse as a condition that requires care and
treatment and which takes freedom from drugs as the ultimate goal – this doxa
means that, according to the theoretical model proposed by McAdam, McCarthy
& Zald (1996), there have been no political opportunity structures in Sweden for
the organisation of drug users, other than for former users or users committed to
quit drugs. One of the consequences of this doxa, which is described in more
detail at the beginning of this article, is that all these organisations have been
very much preoccupied with questions of care and treatment, indeed care and
treatment have been central to the very formation of these organisations. As far
121
as users are concerned, access to strong and effective alternative forms of care
provide a reason for mobilisation, and the provision of effective treatment for
drug addicts enjoys not only political legitimacy, but it is also seen as an
important social duty.
The first organisation, the RFHL, was created as a critical reaction to the way
that society dealt with drug issues, to the way that the authorities and the police
dealt with drug addicts and to the lacking and repressive methods of care. The
environment in which the RFHL was founded was pervaded by a sense of moral
panic: the drug issue had been labelled as a social problem and drug abuse was
seen to be spreading among the youth of the nation. There was a social and
public demand for effective and appropriate methods for dealing with the
problem, as there still existed no system for the care of drug addicts. Society was
also at a loss with the protest movement that was rapidly evolving and that
among other issues was drawing attention to processes of social exclusion. There
were thus both political opportunities and mobilising structures in place, and in
principle all that remained for the active, i.e. radical and progressive forces in
society and users to do was to ride this crest and coordinate the unfolding
activities. The forms of care launched by the RFHL, such as milieu therapy
collectives and contact centres, were incorporated into this structure later on and
eventually became part of the official care system.
In addition to its efforts to develop alternative forms of care, the RFHL has
continued to work to lobby public and political opinion by drawing attention to
the conditions in which drug abusers live their lives. Over the years the
organisation has both changed its form and revised its stance on methadone use,
for example. Initially, the RFHL was opposed to methadone, but after years of
vacillating debate, it eventually decided to change sides.
If the RFHL can be described as an open and politicised movement geared to
change, the self-help movement is its exact opposite. It is introverted,
anonymous and conservative in the sense that there have been no major changes
or shifts from its original setup. Instead, the reason for the dramatic increase in
the number of self-help groups since the mid-1980s is thought to lie in the
successful launch of the Minnesota model in Sweden (Helmersson Bergmark
1998). On the other hand, one may also presume that the large number of selfhelp groups was both as a prerequisite for and served to legitimise the Minnesota
treatment model, which from a Swedish point of view was very short and brief.
These groups provided a convenient way to reach those patients and to provide
them with the aftercare they needed so that they could become “successful
results”, i.e. abstinent abusers. Furthermore, self-help groups were extremely
valuable to the official system which at times of budget constraints could send
their clients/patients to receive care free of charge.
122
Today, organisation among drug users takes place in a society where the state
has withdrawn into a back-seat role, where the nature of abuser care has
changed, and alternative forms of community care have increased at the expense
of institutional bed places. A space has opened up that can be filled by voluntary
forces driven and stimulated by the state. Information campaigns aimed at
shaping public opinion has been downscaled, with the possible exception of the
Swedish Users Union which says it wants to highlight the interests of heroin
addicts. However, the association has originally grown up out of a sense of
dissatisfaction with existing substitution maintenance programmes (methadone
and Subutex) and with the rights situation of many patients.
Like other voluntary organisations, all of those mentioned here, with the single
exception of the NA, work closely with and are heavily dependent on the state.
This may have to do with economic and material resources and opportunities to
participate in public debate. All this marks an extension to and continuation of
the Swedish corporatist tradition, which is characterised by the absence of
confrontational movements in the social policy field. In exchange for resources
they receive, the organisations sell their expertise, their competence and access
to different groups of citizens (Magnusson 2002; Meeuwisse & Sunesson 1998).
However, in the present system of user organisation it seems that the nature of
co-opting has changed. Increasingly, voluntary organisations appear to have
given up their role as advocates and critics at the expense of the role of service
provider. A successful example is provided by KRIS, which has gained broad
public support and recognition for its work and commitment to the Swedish drug
policy of complete freedom from drugs.
All organisations started by users have grown up out of personal experiences of
care. In some organisations, such as the Swedish Users Union for opiate addicts,
the drug of choice is a key criterion for membership, in others members are drug
users in general. Users have become experts on substance abuser care and they
are using their experience and knowledge to help others with similar problems.
The help they offer may vary both in terms of duration, form and content: it may
consist of peer support, voluntary work, work as an employee or self-employed,
and take up a larger or smaller part of one’s everyday life and own identity. In
this way treatment practices, explanation models and knowledge production
around drug use and quitting drugs are not the exclusive domain of professionals
whose expertise is based on formal education. In the long term, this might have
implications for expertise-building on issues of drug use and abuse. As yet, it is
too early to say what exactly those implications might be.
In several organisations user experiences have been transformed into services
that are sold on the marketplace. Taking on the role of service provider creates
various different tensions both for the individual user and for the organisation.
123
For the individual user, this may provide an opportunity to earn an income, gain
social respect and even build a future career, but it may also necessitate various
new roles that carry the potential of serious role conflicts. From the role of
voluntary worker, one moves to become a salaried employee, in a position that
involves certain responsibilities, at the same time as one may be involved in selfhelp groups with other users, sometimes close friends, who are also potential
“clients”. Another problem may come from the difficulty of changing careers
and transferring the capital and status one has built up in this expert role. There
is the risk of becoming trapped in the role of user, albeit a professional one. As
for the organisation, service provision may also give rise to tensions, as shown
by the study of KRIS conducted by the Swedish National Council for Crime
Prevention (BRÅ), if professional users want to present themselves as such and
take up an expert role vis-à-vis other users. The user is placed up against another
user, and it is the one who has been abstinent longer that will emerge as winner,
gaining the rights of interpretation – a practice that is also common in the selfhelp movement, where there are rewards and special privileges for those who
have been abstinent the longest.
User participation today is probably dependent on a cluster of interwoven
factors. The political opportunity structures are in place in so far as central and
local government encourage active engagement and involvement. There are
established forms of voluntary organisation that create the necessary mobilising
structures, which can be taken into use by actors who represent a relatively
limited, well-defined and permanent group of people with fairly similar
problems. Drug abusers have become older, some of them have been through
several treatment regimes, they have experience and knowledge of what is
required in order to quit drugs that they can pass on to others. Some of them
have succeeded, others haven’t. Together with this, the terminology advocated
by the self-help movement has gained ground whereby abuse is understood as a
special identity, as a problem that cannot be treated by means of medication – as
is confirmed by substitution therapy. Here the users are presented as patients, a
legitimate interest group who are capable of articulating their claims for care.
However, this is a group of people who are defined as and who create a
community on the basis of their position in the welfare state, as clients/patients
or users of substance abuser care. The tendency of involving users of welfare
services is seen not only in Sweden but other welfare states as well. Asmussen
(2003) argues that user participation in this latter sense should be understood as
a new technology regarding citizenship. She argues that this is not only about
developing and improving welfare services with a view to adapting them to
current target groups, but also about steering citizens’ behaviour towards the role
of active citizen who assume responsibility for themselves.
The question now is whether user organisations will find and content themselves
with the place appointed to them by the state and work within mainstream
124
society to build “sheltered islands” in the shape of work collectives, day
activities, leisure activities, etc. where they make use of their members’ personal
experiences and where their situation is established. Alternatively, it is possible
that users will consciously and strategically produce a shared view of their
environment and themselves and in this way create “islands of meaning and
opposition” that project into mainstream society and in the future come to
challenge the prevailing doxa.
Translation: David Kivinen
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127
The Development of User Influence
on Swedish Drug Policy 1965–2004
Björn Johnson
Introduction
The aim of this article is to investigate the degree to which Swedish drug users
have been able to influence Swedish drug policy from the mid 1960s onwards,
the time during which drug abuse was established as a social problem. I will also
try to determine in which areas their influence manifests itself. Influence is
meant in a political sense and the article does not shed any light on whether
individual users have managed to exert an influence over their own situation.
The focus is rather on the relationship between public drug policy and the
opportunities of the users to carry clout as a collective.
In the last decade, Scandinavia has experienced a mobilization of drug users.
This mobilization was initiated in Denmark where the first Scandinavian
association of drug users was founded in 1993. Since then user associations have
sprung up also in Norway (1996) and Sweden (2002).
It may perhaps seem natural to interpret this development in light of the
increased interest in user influence and other forms of civic participation that
followed on from the discussions about participatory democracy during the
1990s. However, in this study I show that such an interpretation would be
insufficiently rigorous. Ever since the early 1980s, Swedish users have had little
say when it comes to drug policy, and in later year this influence has diminished
rather than increased.
In this article, the term user carries a double meaning in the sense that it refers to
both someone who uses drugs and to someone who is subjected to or benefits
from public measures. The first definition of the term – the drug user – is
relatively unproblematic in this context, but the second meaning merits a further
discussion. In administrative science, and when discussing user influence in
general, a distinction is normally made between four different definitions of the
term user (Dalhberg & Vedung 2001). According to the most common
interpretation a user is the recipient of various types of public benefits in the
form of services or goods. This definition is sometimes qualified in the sense
that a distinction is made between recipients who themselves are able to choose
services or goods – the user is a public services ‘customer’ – and recipients
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without any such options. According to the fourth and widest interpretation a
user is the recipient of public measures in general, that is to say of both public
benefits as well as public rules and regulations and exercises of public authority.
I am using this broader definition. Consequently, the users in this article mainly
constitute active drug users who are recipients of public benefits – such as
treatment of their drug addiction – as well as subjected to public rules and
regulations and exercises of public authority; such as drug-oriented control
policies.
Arguments in favor of user influence are usually associated with and motivated
by some form of participatory democracy perspective. However, you do not need
to be an adherent of participatory democracy to take the view that the opinions,
interests and experiences of the drug users should in some way be taken into
account and be allowed to influence Swedish drug policy. The various policy
components – control policies, drug addiction treatment and preventive measures
– all contain such a great measure of exercise of public authority that the
importance of listening to the users can be argued, even from a parliamentarian
or elitist-democracy point of view.
Dahlberg and Vedung (2001, 43–65) discuss six different ideal-type arguments
for user influence. The civic education argument aims at achieving civic
instruction through user influence. The expressivity argument focuses on the
users’ opportunities for self-fulfillment through the influence process. The
legitimacy argument brings up the benefits in terms of legitimacy that decisionmakers and administrators can achieve through user influence. The point of the
efficiency-oriented argument is that user influence can lead to better goal
fulfillment and increased administrative efficiency. The power leveling argument
claims that user influence can reduce the imbalance in power that exists between
decision-makers and administrators on the one hand and the users on the other.
The reasoning behind the service adaptation argument, finally, is that user
influence can lead to the public measures being adapted to meet the users’ needs
and requirements. In theory, all of these arguments could be used to motivate the
users having an influence over Swedish drug policy. In most cases, organizations
safeguarding the interests of users favor power leveling, service adaption,
efficiency or expressivity arguments, i.e. mainly arguments aiming to increase
the benefits to the users.
The first question that has to be asked when discussing user influence is,
‘influence over what?’ The term ‘drug policy’ is too wide and needs to be
qualified and delimited. One way of doing this is by making a distinction
between different spheres of influence. Burns et al. (1994), for instance, identify
an individual sphere which concerns public measures for separate individuals or
households in their own environment, a program sphere for individual or
collective contacts with public services (such as schools, health centers or
treatment clinics), a municipal sphere where individuals and groups come into
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contact with municipal politics and administration, and finally a governmental
or public policy sphere for contacts between individuals and groups on the one
hand and key political and administrative authorities on the other. The main
topic of interest in this essay is how users’ interests and influence have been
articulated in the fourth sphere – the Swedish public drug policy. By ‘public’ I
am primarily referring to all centrally decided and administered laws, rules and
regulations (i.e. by parliament, government and key government departments and
agencies).
User-oriented studies usually deal with one of the first three spheres, whereas
decisions made in the fourth sphere are seldom discussed in a participatory
context. This is somewhat remarkable considering the fact that this sphere is of
great importance to the other three; decisions in the governmental (public policy)
sphere essentially draw up the boundaries for decision-making in all other
spheres. Michael Lipsky (1980, 14) has formulated this neatly and succinctly:
The major dimensions of public policy – levels of benefits, categories of
eligibility, nature of rules, regulations and services – are shaped by policy elites
and political and administrative officials. Administrators and occupational and
community norms also structure policy choices of street-level bureaucrats. These
influences establish the major dimensions of street level policy and account for
the degree of standardization that exists in public programs from place to place
as well as in local programs.
The second delimitation concerns the time period under study. The period under
investigation more or less covers the entire history of the modern Swedish drug
issue. I have studied user influence on drug policy all the way from narcotics
emerging as a social problem in the mid 1960s through to the early 2000s. The
reason for this relatively long time span is that it has given me an opportunity to
paint a more comprehensive picture of user influence on public drug policy from
a perspective of social change.
The user influence discussion demands, apart from a clarification of what is
meant by ‘drug policy’, a discussion of the term ‘user influence’. In this context I
would like to make a distinction firstly between substantial influence and
secondly processual influence. Substantial influence is the question of the
contents of the policy, i.e. the degree to which a drug policy has managed to
produce results that are in the users’ interest, while processual influence
concerns the forms for the decision-making or, put another way, the degree and
the way in which users have been allowed to participate in and influence the
decision-making process. These terms will be discussed in more detail later.
I will begin by discussing the processual influence of Swedish drug users on the
public drug policy, and then move on to their substantial influence. The essay
concludes with an integrated analysis of user influence, where I also discuss a
couple of interesting points of principle about the results.
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Processual Influence
In processual terms user influence is also a question of the degree and the way in
which users or representatives of user and client organizations are allowed to
participate and influence the decision-making process. For the purposes of this
study, I have regarded as such organizations that either organize drug users or
explicitly claim to represent a user interest. In this study, the former type is
represented by Svenska Brukarföreningen (The Swedish Users Union), and in
the latter group, Riksförbundet för hjälp åt läkemedelsmissbrukare (RFHL,
National Association for Aid to People Addictive to Drugs and Pharmaceuticals)
stand out in particular, but here we also find some of the associations in the
client movement that was founded in the 1960s and 1970s – such as
Riksförbundet för kriminalvårdens humanisering (KRUM, The National
Association for Humanizing the Treatment of Offenders) and Riksförbundet för
social och mental hälsa (RSMH, National Association for Social and Mental
Health).63 Henceforth, I will use the term ‘user organizations’, even when
discussing organizations which more accurately should be termed client
organizations. It should be noted that I have disregarded the self-help movement
founded in the 1980s, in this context mainly represented by Anonyma
Narkomaner (NA, Narcotics Anonymous). The reason is that NA have chosen
not to participate in the drug policy debate and deliberately avoided taking a
stance on drug-related issues such as criminality, legality, prostitution and harm
reduction.
Let me first of all point out that it is hardly reasonable to expect individual users
to be able to influence the decision-making on public (i.e. within the framework
of what I above termed the fourth sphere) drug policy. The most important
decisions at that level are first and foremost taken by Riksdagen (the Parliament)
and the government, and secondly within key government departments and
agencies. Drug users are often socially marginalized with a weak position in
society. In general, these people have neither the time, the interest nor the energy
63
RFHL, the most prominent organization, was founded in 1965 in reaction to the
increased influence of the police and the judicial system on drug policy. The point of the
RFHL message was that rather than persecuting them, drug users should be offered
treatment. RFHL quickly became an important voice in the drug policy debate, and in
the 1970s the association turned into the most influential of the so called ‘Rassociations’ (R as in Riksförbund, National Assocation), a number of client
organizations working to provide support for and influencing public opinion in favor of
drug addicts, alcoholics, mentally ill and criminals. The guiding principle for the Rassocations was that also the people subjected to the social policy should have their say.
Consequently, in the 1970s the R-associations played a relatively important role for the
development of treatment element in social policy (see also Leili Laanemet’s article in
this publication).
131
to try to influence public policy-making, regardless of the impact such decisions
may have on their own situation. It is therefore reasonable to assume that the
processual influence of individual drug users will predominantly take place
within the framework of the first two spheres – the individual and program
spheres – for instance in their interaction with social workers, treatment clinic
staff and the forces of law and order.
However, individual participation is not strictly speaking a hard and fast
requirement in order for us to be able to talk about processual influence. In
Sweden, public inquiries, i.e. commissions appointed by the government, have
long been an important and characteristic element in the consideration of issues
decided by the authorities (Zetterberg 1990). Nearly all important reforms in
society tend to be preceded by public inquiries (ibid.). Within the public inquiry
framework various types of organizations are often given the opportunity to give
their views on current political issues. The result of the inquires is generally
presented in the form of one or more commission reports, which are then
referred for comment. This means that a number of referral bodies – government
agencies, organizations, sometimes also individuals – are given the opportunity
to voice their opinion on the proposals of the commission.
The public inquiry framework fill three important objectives in the Swedish
political system: as a drafting body for the government (and sometimes also for
political parties or other organizations); as a public arena for cooperation and
confrontation between various interest groups in society; and finally, as an
important conduit for collating and producing knowledge (Zetterberg 1990).
The Swedish drug policy has been subject to comprehensive public inquiries
several times. In so far as users and user organizations have been given the
opportunity to participate in the decision-making process on public drug policy,
it should be possible to trace this influence in the commission reports. A scrutiny
of the more important drug policy inquiries should therefore serve as an
indicator of the extent to which users and user organizations have been allowed
to exert a processual influence over the fourth (the governmental) sphere of drug
policy.
The processual influence takes several forms within the Swedish public inquiry
framework: Firstly, the processual influence of users may be an explicit purpose
of the inquiry and will then normally be reflected already in the remit of the
inquiry. Secondly, processual influence may be exerted by including
representatives of user organizations on the panel of the inquiry, either as
members of the commission, as secretaries, specialists or experts linked to the
inquiry, or as members in one of the reference groups that are often connected to
the inquiries. Thirdly, processual influence may also be exerted during the work
of the inquiry, while the commission panel consults users or representatives of
user organizations. User influence may, fourthly, take place during the
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consultation process when users or user organizations are given an opportunity
to voice their opinion of the commission report. Finally, a user perspective may
be included in the commission report, regardless of whether users or user
organizations have participated in the inquiry in any other way. For a user
perspective to be considered to be present, I have put down as a criterion that
drug users should figure as a subject in the text in the sense that their views,
opinions or (subjectively experienced) interests and living conditions are
explicitly discussed in the report. In those cases I have chosen to see the
presence of the user perspective as an indication of a certain amount of indirect
processual influence, regardless of whether any real involvement occurred or
not.
The Material
The main body of material of my study of the processual influence comes from
the three major drug policy inquiries that have been conducted in Sweden.
Narkomanvårdskommittén (The Committee for the Treatment of Drug
Addiction), the first public drug inquiry, was conducted 1966–1969. This inquiry
was launched as a result of the mobilization that had taken place in the drug
policy debate in the early 1960s. In 1967 two reports were published, SOU
1967:25 and SOU 1967:41, that were to gain great importance. Based on the
proposals made by the commission in those reports, the Parliament opted for a
drug policy which saw the judicial system tightening its grip on issues of drug
use, while at the same time placing much of the responsibility for preventive
measures and treatment in the hands of the social services. In 1969, another two
reports were published, SOU 1969:52 and SOU 1969:53. All four reports of the
commission is included in this study.
1982 års Narkotikakommission (The 1982 Drugs Commission) operated between
1981 and 1984. This inquiry was launched as a result of an increased consensus
among the political parties for the need of a stricter public drug policy. The remit
of the commission was to outline the basis for a coordinated and intensified war
on drugs, with a particular focus on control policy measures. Issues regarding the
treatment of drug addiction were not part of the remit, however. The main report
of the commission, SOU 1984:13 is included in this study.
1998 års Narkotikakommission (The 1998 Drugs Commission) operated during
the period 1998–2001. This inquiry was motivated by a desire for a
comprehensive review of the Swedish public drug policy. The directives stressed
that the overarching objective for the Swedish drug policy – the vision of the so
called drug-free society – should remain in place. The main report of the inquiry,
SOU 2000:126 have been studied for this article.
133
The above-mentioned inquiries all had a broad remit in order to allow a
comprehensive view on the development of Swedish drug policy. Apart from this
material, I also include commission reports concerning two central user issues,
namely the issues of compulsory vs non-compulsory treatment of drug addiction
and the criminalization of personal drug use.64
In 1980–97, Socialberedningen (The Social Commission) conducted an inquiry
into the issue of compulsory treatment.65 Only one of the Social Commission’s
many publications, namely the first commission report, SOU 1981:7 is included
here. This report formed the basis for the LVM Act (Lagen om vård av
missbrukare i vissa fall, The Treatment of Addicts in Specific Cases Act), which
came into force in 1982. The Social Commission’s main report, SOU 1987:22 –
which led to the LVM Act being revised and reinforced – have not been included
in the study.
The issue of criminalization of personal use entered the agenda in the mid 1970s
and the debate intensified considerably towards the end of that decade. In the
early 1980s the issue was taken up by the Drugs Commission, but the legislation
was left unchanged at this point. The main reason for this was that the Social
Democrats took a sceptical view of criminalization. Towards the mid 1980s,
however, the party’s stance on this issued started to change, and in 1986 time
was considered ripe for a criminalization. The issue was investigated internally
at the Department of Justice, and in 1988 the Parliament passed a law on
criminalization. Some years later the issue was once again the subject of an
intradepartmental inquiry, leading to an increased penalty, from a fine to a fine
or a custodial sentence up to six months. The two memoranda from the
Department of Justice, Ds Ju 1986:8 and Ds 1992:19 are included in this study.
Results
The following table lists the results of the review on the evidence on processual
influence of drug users in the five inquiries studied:
64
65
See the section on substantial influence for a more detailed discussion of the term
‘central user issues’.
Please note that the work of the Social Commission did not exclusively concern drug
policy issues, but also compulsory treatment of alcoholics.
134
Table 1. Overview of processual influence.
The Committee
for the
Treatment of
Drug Addiction
(Narkomanvårdskommittén)
The Social
Commission’s
Treatment of
Addicts in
Specific Cases
Act (LVM Lagen om vård
av missbrukare i vissa
fall)
1982 Drugs
Commission
(Narkotikakommissionen)
Dep. of Justice
Criminalization
Memoranda
1998 Drugs
Commission
(Narkotikakommissionen)
Remit
Commission
Panel
Yes
Work of
Commission
Yes
Yes
Yes
Commission
Report
Consultation
Process
Yes
Yes
Yes
Yes
Yes
As indicated by the above table, the processual influence mainly occurred during
the consultation process and in the work of the commissions. As far as the
consultation process is concerned, in each and everyone of the inquiries
examined at least one user organization was given the opportunity to voice an
opinion on the commission reports. At first glance this seem all good and very
well, but there are certain factors making such a conclusion less clear-cut. First
of all the Swedish referral system contains a fairly substantial element of
routinism and ritualism; commission reports are rather sent to too many than to
too few consultation bodies. The fact that an organization or a government
agency has been asked to supply a comment on a commission report does not
mean that the authorities will listen to their opinions on the matter, or even had
the intention to do so in the first place. Secondly, in the three latest inquiries
covered by the study only one organization claiming to represent drug users –
RFHL – was allowed to comment. This is rather paltry, and considering the fact
that RFHL ever since its foundation in 1965 has been a very important
organization in the debate about Swedish drug policy it would have raised more
eyebrows if it had been passed over.
135
As for processual influence during the work of the commissions, this is in
evidence in the three major drug policy inquiries. In each case, RFHL was the
only user-oriented organization asked to participate, despite the fact that in
general a great many organizations and government agencies were invited to
these consultation rounds. Also in these instances, considering RFHL’s towering
presence in the debate, it would have been more remarkable if the organization
had not been invited to take part. The fact that the Social Commission did not
ask RFHL to give their view can, in all likelihood, be explained by that they
were working under intense time pressure. Another contributing factor was
probably the fact that the government more or less had made up its mind at that
stage and that they already knew what RFHL thought of compulsory treatment.
This latter factor was even more strongly manifested by the memoranda on
criminalization from the Department of Justice; they were ‘tailor-made’ and took
the form of technically inclined judicial inquiries.
Being a member of the inquiry commission – or one of its working parties – is
arguably the most effective form of processual influence. User organizations
definitely exerted this type of influence in one case, the Committee for the
Treatment of Drug Addiction. Moreover, in this instance the influence probably
was relatively great as representatives of RFHL filled several posts in the allimportant secretariat. But perhaps this was nothing to be surprised at; at the time,
RFHL was by far the largest and most well organized NGO on the drug policy
arena. Considering that RFHL also later has played an important role in this area
it is all the more surprising that the association was never offered a regular place
on any of the subsequent inquiries reviewed in this study. This may at least
partly be explained by the fact that in recent decades we have seen a general shift
in the inquiry system towards a more professional, but also downsized make-up
of committees as well as secretariats.
In two areas of influence – the remit of the inquiry and a user perspective in the
commission report – there was no processual user influence at all. As for the
remit this is not so surprising; inquiry remits tend to be very general in character,
rarely spelling out which interest groups should be given a hearing. However, the
lack of a user perspective in all commission reports investigated is all the more
remarkable. The Committee for the Treatment of Drug Addiction was the only
inquiry where at least an attempt was made at approaching the drug users. The
reports of the commissions detail a number of investigations into more objective
factors – such as gender, criminal record, substance preferences and usage
patterns – but they contain no information about the users ‘as human beings’.
In fact, the objectification of the drug user is well nigh universal in all reports
that I have studied. When drug users are mentioned it is as subjects for measures
or statistical categories, not as human beings with experiences, opinions and
feelings. Even in cases where one would expect to be able to trace a user
perspective – when it comes to care and treatment – there is scant little evidence
136
of it. The latest major commission report, “Vägvalet” (“At the Crossroads”), the
final report of the 1998 Drugs Commission, discusses the importance of
“ensuring that the analysis is based on the client’s individual needs and current
situation” (p. 167) when choosing treatment methods. It is clear, however, that
the term ‘needs’ should be interpreted as an objective client ‘condition’, not
something that has got anything to do with the client’s own wishes or
expectations.
Thus the only conclusion that can reasonably be drawn from the empirical
material is that users and user organizations have had a very limited processual
influence over public drug policy, at least since the early 1980s (given obviously
that a study of processual user influence on major public inquiries is a good
indicator of processual influence in general). The only inquiry that stand out in
the sense that the RFHL client organization actually exerted a real processual
influence, is the Committee for the Treatment of Drug Addiction’s inquiry 1966–
1969. However, we have already touched on a possible explanation for this, i.e.
that RFHL at the time basically was the only NGO extant in the field of drug
policy.
The fact that the users’ processual influence over public drug policy has been
limited or non-existent does not necessarily mean, however, that the same can be
said of their substantial influence as well. The question of the extent of the
substantial influence of users and user organizations over policy can only be
answered by empirical studies, which leads us on to our next section.
Substantial Influence
Initially I mentioned that the users’ substantial influence over public drug policy
centers on their opportunity to influence the actual contents of the policy.
Another way of putting this is that substantial influence is a question of the
degree to which a drug policy produces results that reflect the interests of the
users. Before we go on we need to clarify what those user interests are. In this
context there are various conceivable interpretations of the concept of interest.
First of all, a basic distinction can be made between objective and subjective
interests.
The term ‘objective interests’ is often used to indicate the needs and rights of
individuals, or, the demands and wishes if they would have been more
knowledgeable (see e.g. Lukes 1974). One obvious criticism of this perspective
is that it is difficult to tell who should decide what those objective interests are
(Benton 1981). Furthermore, an objective analysis of user interests would also
lead to the conclusion that, first and foremost, it is in the interest of the user to
stop taking drugs – something which is not necessarily what the users are
137
looking to do, and something that also goes against the grain of the whole idea of
users being worth listening to in the first place.
The subjective interests, in contrast, are governed by the actual demands or
wishes of the individual, either now or in the future. The subjective interests are,
in other words, self-experienced. There are several conceivable methodological
strategies for clarifying the subjective interests of Swedish drug users. Firstly,
one can investigate articulated user interests. However, drug users are seldom
heard in the general debate in Sweden, which makes it hard to find examples of
such explicit interests. In those cases where individual users do take part in the
debate the problem crops up of whether they can be regarded as representative
for the wider user collective. Secondly, we have organized user interests. Today
there are branches of the Swedish Users Union in Stockholm and other towns
and cities, as well as other associations working to organize drug users (at least
as part of their activities). In a longer historical perspective, however, few
organizations have aimed at mobilizing the users. Client organizations, such as
RFHL and KRUM, can in certain respects be said to have represented the user
collective, as discussed above.66 Thirdly, interests can be derived from
international comparisons. This is, in my view, the most promising way of
studying user influence. The point is that the interests of Swedish drug users can
reasonably be expected to be similar or identical to those of organized users in
other countries. The interests of Swedish users can thus be postulated by looking
at user issues pursued by user organizations in other countries.
I have primarily adopted the latter strategy for my analysis, complementing it
with the second strategy. I started, in other words, by collating a catalog of issues
and standpoints pursued by user organizations in a number of countries. Then I
compared this catalog with the issues and standpoints pursued by Swedish user
organizations. In the Swedish context I have mainly focused on the client
organization RFHL and on the Swedish Users Union. In RFHL’s case this is due
to the fact that this is the largest and, at least in a historical perspective, by far
the most influential user oriented organization. In the second case the reason is
that the Swedish Users Union was the first Swedish organization to explicitly
work in the interest of active users. Based on this comparison I subsequently
studied the development of Swedish drug policy – from the end of the 1960s to
the early 2000s – from a user perspective. In this task I have primarily used
secondary sources, such as sociological, criminological and political science
literature on the Swedish drug issue and Swedish drug policy.
User Issues and Standpoints
66
See the articles by Jessica Palm and Leili Laanemets in this publication for a more
detailed discussion of the backgrounds of and ideologies behind i.e. SBF and RFHL.
138
The catalog below was compiled by searching the Internet for issues pursued by
user organizations in nine countries: Australia, Canada, Denmark, Germany,
Great Britain, The Netherlands, Norway, Sweden and USA.67 Some of the
organizations are relatively young (such as the user associations in Norway and
Sweden), but many of the others are of relatively long standing. The unanimity
as regards issues and standpoints pursued by the various organizations have been
comparatively comprehensive, both in terms of time and geography. In this
fashion I was able to identify five issue complexes, commonly found on the
agenda of many of these organizations. They will be discussed separately in the
forthcoming sections:
•
One complex of issues concerns a user’s rights and position in society.
All user organizations in the study are working to make visible drug
users and their social plight. In connection with this the importance of
creating new social networks for the users – often within the framework
of the user organization – is often stressed, as well as a widening the
interface and access to the social security network.
•
Another issue complex concerns drug addiction treatment and access to
it. In this context, user organizations are working to ensure that places at
detoxification and treatment clinics are available on demand, i.e. when
the user him- or herself is motivated or ready to seek treatment. User
organizations are also working to provide a broad spectrum of treatment
options, and to ensure that the treatment is individually adapted and
planned in consultation with the client. User organizations are by and
large opposed to compulsory treatment
•
A third set of issues involves the degree of repression in the control
system. In general, user organizations are of the opinion that the control
system should be as humane as possible and that the criminalization of
users should be avoided as far as possible. The specific issues vary from
country to country, but concrete examples are opposition to
criminalization of possession and personal use of classified substances,
lowering various penalties for drug-related crime and issues regarding
the incarceration systems. In some countries user organizations are
active on whether cannabis should be legalized or not.
67
In total I reviewed eleven organizations: AIVL – The Australian Injecting and Illicit
Drug Users’ League (Australia), UNDUN – Unified Networkers of Drug Users
Nationally (Canada), VANDU – Vancouver Area Network of Drug Users (Canada),
DDUU – Brugerforeningen (Denmark), Jes-Bielefeld e.V. (Germany), Junkie Bund
(Germany), The Alliance (Great Britain), MDHG – Belangenvereniging voor
Druggebruikers (The Netherlands), BrukerForeningen i Tønsberg (Norway), Svenska
Brukarföreningen (Sweden), and Springfield Users’ Council (USA). The URLs to the
home pages for these organizations can be found in the list of references.
139
•
A fourth issue complex concerns harm reduction measures. All user
organizations in my study are pressing one or more issues regarding
harm reduction measures. Common issues are access to methadone
maintenance treatment, needle exchange programs and access to public
spaces where the users can congregate without fear of harassment. In
connection with the latter issue, demands are sometimes heard for
injection rooms or similar facilities. Less common issues are things like
regular prescription of heroin.
•
The fifth set of issues, although closely connected to harm reduction,
concerns health care and information. These issues are often about what
help users can get to protect themselves against infectious diseases and
overdosing. In this context demands are often voiced for public-service
involvement, partly by widening the access to health care for users (for
instance by extending health care resources to places where users can be
found), and partly by financing or organizing information campaigns, the
distribution of condoms and the like.
The Rights and Position of Users in Swedish Society
The issue of users’ rights and their position in society is on the agenda, directly
or indirectly, of all user organizations in the international sample. However, the
issue of rights is often connected to more drug policy-specific questions, such as
the aim of control policies and access to treatment. In this section I will therefore
limit myself to some general reflections on drug users as members of society.
On a purely formal level there is no question of drug users not enjoying the same
status as other citizens in Swedish society. With one notable exception there are
no formal obstacles for users who want to exercise their civic rights. The
exception is, of course, the fact that the use of classified substances has been
illegal in Sweden since 1988, something which in practice means that the users
themselves are criminalized to a certain extent. However, I will return to this
issue in more detail when discussing the control system.
Although there is no formal discrimination of drug users in Swedish society, it
can be reasonably assumed that in practice a substantial amount of negative
discrimination occurs in their contacts with social welfare institutions. For
instance, known drug users tend to attract inordinate attention from the police,
something which can be seen as a form of negative profiling (cf ‘racial
profiling’). Furthermore, in many instances access to health care is in all
likelihood more restricted for drug users, even when allowances are made for
deficiencies caused by their own actions.
140
It is a well established fact that the public sector cutbacks of the 1990s hit many
vulnerable groups in the Swedish society especially hard. There is every reason
to believe that this was a major contributing factor behind the comparatively
large increase in heavy drug use that took place during that decade (Olsson 2001;
CAN 2004). Whether there is a connection between this increase and the
development of public drug policy during the same period is, however, not easy
to say. As Olsson (2001, 94) notes, drug policy has only a limited impact in the
grander scheme of things when it comes to the drug situation. More important
are things like poverty, youth unemployment, marginalization, global trends in
youth culture and a number of other social conditions.
The Swedish Drug Addiction Treatment Framework from a User
Perspective
Drug addiction treatment is a central issue complex for all user organizations in
my study. These issues center around the extent and planning of treatment as
well as access to it, but also the issue of compulsory treatment looms large. In
the following section I discuss the development of Swedish drug addiction
treatment from a user perspective, focusing specifically on the role of
compulsion. However, I leave the important question of methadon for the section
on harm reduction measures. The reason for this is that in my global user
organization sample, methadone is usually discussed in the context of harm
reduction.
The Development of Drug Addiction Treatment68
Around 1970 the treatment of drug addiction was increasingly transferred away
from psychiatric hospitals. This led to a distinctive drug addiction treatment
framework, independent of the health care system, being established in Sweden.
A comprehensive treatment apparatus consisting of treatment clinics, health
centers and advice bureaus sprang up (Hilte 1990). The first half of the 1970s
saw a steady increase in the resources earmarked for drug addiction treatment,
while at the same time there was a shift from one system – psychiatric care – to a
loosely organized and unwieldy treatment framework based on social authorities
(Bergmark 1998). This development relaxed the grip of the medical profession
over drug addiction treatment, allowing social workers, psychologists and other
behavioural scientists to gain ground. The client organization RFHL took a very
active part in this development by, amongst other things, initiating and running
several new therapeutic communities.
68
See also Leili Laanemets’ article about the restructuring of the Swedish addiction
treatment framework in this publication.
141
This expansion continued apace during the second half of the 1970s, at the same
time as the so called Hassela principles attracted ever more attention in Sweden.
The first Hassela community was founded in 1969. The idea behind Hassela was
to treat young addicts aged between 15 and 20 years of age. The Hassela
principles emphasize education and fostering social responsibility (Hilte 1990).
The method is relatively authoritarian in character, often with elements of
compulsion, something which RFHL took a very sceptical view of.
The second half of the 1980s saw the expansion of the drug addiction treatment
framework gaining new momentum as the authorities feared an HIV epidemic
among the drug users. The government’s action plan for fighting Aids (prop.
1987/88:79) stressed the importance of tracking down drug users and offering
them drug-free treatment. In practice this meant that Socialstyrelsen (The
National Board of Health and Welfare), among others, during the latter part of
1980s supported the creation of a specialized open treatment framework at local
and regional level. Institutional care also expanded during the same period
(Socialstyrelsen 1993; Bergmark 1998). In the period 1986–1991 the total
number of treatment places increased by some 50 per cent, with outpatient
treatment taking the lion’s share of this increase (Socialstyrelsen 1999).
The economic downturn in the 1990s resulted in a marked worsening of the
financial situation for local and county councils. According to some analysts this
also led to a drastic decline in the treatment of drug addicts. Judging from the
statistical data presented by the National Board of Health and Welfare to
Kommittén för välfärdsbokslut över 1990-talet (The Welfare Accounts
Committee for the 1990s) in 1999, however, no general reduction in the
resources set aside for drug addiction treatment seems to have taken place,
although many individual local councils did cut back spending (Socialstyrelsen
1999). The institutional framework for drug addiction treatment has declined
noticeably, but this has to some extent been offset by an increased access to
outpatient treatment (SOU 2000:126).
All in all, it seems that the resources for treatment of drug addiction were
roughly the same in the early 2000s as they were in the early 1990s. But in light
of the increase in the number of addicts during the 1990s the picture becomes
more gloomy. Most available indicators show a steady increase in substance
abuse throughout the 1990s. The number of heavy users, for instance, increased
by nearly 40 per cent between 1992 and 1998 – from 19,000 to 26,000 people
(CAN 2004). Such figures lead us to the obvious conclusion that the drug
addiction treatment framework, which quantitatively speaking saw a positive
development until the end of the 1980s, has undergone a significant decline in
the last fifteen years.69
69
The quality of the treatment of drug addiction is, of course, also an important factor. A
knowledge survey from SBU (SBU 2001) indicates that in many cases the quality of
Swedish drug addiction treatment can be called into question. The lack of scientifically
142
Compulsory Treatment
The issue of compulsory treatment turned into one of the major conflicts in the
drug debate of the 1970s. On one side in this conflict stood the client movement,
championed by RFHL and supported by the National Board of Health and
Welfare for one. RFHL pressed for a treatment structure based on consent and
were categorically opposed to the idea of compulsory treatment. The influence
of RFHL had been a contributing factor when the Parliament in 1972 decided
that voluntariness should be the guiding principle in the treatment of drug
addiction.
Across the divide stood some of the real drug policy hardliners, such as
Föräldraföreningen mot narkotika (Parents Against Drugs) and the Hassela
movement. Hassela’s treatment clinics had come to be regarded as highly
successful towards the end of the 1970s, a contributing factor behind the more
positive attitudes towards a compulsory element in addiction treatment. An
important consequence was that RFHL gradually lost its role as the leading NGO
in the drug policy field.
In 1981, the LVM Act concerning treatment of addicts in specific cases was
passed which widened the scope for compulsory treatment. The object of the
LVM Act was first and foremost to encourage patients to seek voluntary
treatment. The treatment period was initially restricted to two times two months.
In 1989, many aspects of this act were reinforced, one of them being an increase
of the maximum treatment period to six months. Of the organizations opposed to
this, RFHL were one of the most negative. Their stance was based on research
showing that long periods of compulsory treatment had no effect and could even
be detrimental.
The cutbacks during the 1990s led to a steady decrease in the number of LVM
cases throughout almost the entire decade. Nevertheless, in 2000 over 1,100
people in Sweden were still to be found in compulsory treatment, most of them
for alcohol addiction. At the same time, compulsory treatment was virtually
unheard of in Denmark, Finland and Norway (Stenius 2001). Despite a reduction
in the number of cases of compulsory treatment, the demands for budgetary
restraints may have forced the local councils to set aside part of their
acceptable reviews has been a constant problem; generally speaking, only the
medication-based maintenance therapies for opiate addiction have been subjected to
rigorous appraisals (see Johnson 2005).
143
institutional care resources for these LVM cases, rather than for those who had
decided to seek voluntary treatment for their addiction (Ekendahl 2001, 29).
The negative attitude of the Swedish client movement towards the compulsory
treatment act has been moderated slightly in later years. RFHL have for instance
suggested a shorter compulsory treatment option where the period of treatment is
limited to a maximum of one month (Svensson 2003). It should also be pointed
out that surveys and other scientific studies have shown that many of the users
who have been committed under the compulsory treatment act have not rejected
it out of hand. A great number of the LVM patients in Bengt Svensson’s (2003)
study of the compulsory treatment system, for instance, took a mainly positive
view of their committal and many of the others saw it as containing both positive
and negative aspects.
The Swedish Control System from a User Perspective
As previously mentioned, user organizations in general are of the opinion that
the drug control system should be as humane as possible and that a far-reaching
criminalization of users should be avoided. In Sweden, ever since its foundation
the client organization RFHL have voiced similar opinions, and the same can be
said for other user oriented organizations, such as KRUM. So how to judge the
development of the Swedish control system from a user perspective?
In the Swedish drug policy debate it is often said that Sweden in the ten years
from 1965 to 1975 had an unusually liberal drug policy in a global perspective.
However, this is hardly consistent with reality. It is rather the case, as Börje
Olsson notes, that Sweden ever since the end of the 1960s has had a “massive
drug policy with strongly repressive elements alongside major – from an
international point of view – information campaigns and preventive measures as
well as treatment and rehabilitation on a broad scale” (Olsson 1994, 172, original
italics). There is no denying that in terms of control policy we have seen a
reinforcement on several levels since the 1970s, but this development was
initiated as early as 1968, and ever since then legislation has gradually become
more repressive (van Solinge 1997; Tham 1995; Tham 1998).
The control policy report of the Committee for the Treatment of Drug Addiction
in 1967 (SOU 1967:41) led to the Parliament adopting a specific drug penal code
(1968:64) the following year. By drawing up a comprehensive piece of drug
legislation the Parliament wanted to signal that society did not accept drugs and
that drug abuse was taken seriously. At the same time, however, they wanted to
make a distinction between sellers and distributors on the one hand and users on
the other, the point being that the users as such should not be punished by the
new law (Träskman 2003).
144
The first years of the 1970s saw a couple of increases in the penalties for serious
drug crimes, but it was not until the second half of the decade that control policy
issues started to dominate the drug debate in earnest. Drug abuse became an
election issue in the run-up to the 1976 general election and after their victory,
the right-wing government announced tougher measures against drugs. From an
earlier situation where the efforts were mainly geared towards the drug trade, i.e.
the supply side, control policy measures now increasingly took aim at the users
themselves. Behind this change lay intense lobbying by drug policy hardliners.
Since the users constitute the only irreplaceable link in the drugs chain that is the
place to strike, the argument ran.
In other words, the focus of the control policy shifted from the producers to the
consumers (Tham 1998). Leif Lenke and Börje Olsson make the following
analysis:
By the end of the 1970s, it is reasonable to say that Swedish drug policy had
shifted its profile. The focus had moved from international syndicates and the
treatment of “drug victims” to a police-oriented strategy whose objective was to
clear the streets of drug pushers. These were to be placed in compulsory
treatment to stop this “contagious disease,” which is how drug use was portrayed
to the public. (Lenke & Olsson 2002, 69)
The early 1980s saw a further reinforcement of the penal code as well as a more
rigorous application of it. But it did not stop there; the number of drug squad
officers increased, as did the numbers sent to prison for drug-related crimes and
the number of drug users in the prison population (Tham 2003). With these extra
resources the police targeted drug dealers at the street level, and in only a few
years the number of arrests doubled (Eriksson & Eriksson 1983; Tham 1998).
This development continued apace when the Social Democrats returned to power
in 1982; during their time in opposition they had moved ever closer to the drug
policy of the right-wing parties.
Although it is probably safe to say that drug abuse on the whole did not increase
significantly in Sweden in the 1970s and 1980s, it was portrayed and seen as a
growing problem (van Solinge 1997; Tham 1998; CAN 2004), leading to a form
of control policy consensus in the second half of 1980s (Tham 1995).
Characteristic of this consensus was the hard line being pursued at all levels
(Träskman 2003). The most important example of this was the Parliament in
1988 with a large majority voting in favor of criminalizing personal use of
classified substances. During 1970s there had been an overwhelming opposition
to a criminalization, but in only a few year this resistance had virtually melted
away. RFHL were one of the few voices who opposed the decision to criminalize
possession.
Five years later the maximum penalty for personal use was increased from a fine
to a prison sentence of up to six months. The primary reason for this increase,
145
however, was not a particular wish to mete out prison sentences, but rather to
ensure a strict and consistent penal code while at the same having the
opportunity to use urine samples and blood tests in order to control whether drug
use had occurred (impossible as long as the maximum penalty was a fine).
The 1990s saw the control policy development level out; for example, there were
no further penalty increases. However, the graph charting the number of drug
squad officers continued its steep incline during the first half of the decade and
leveled out only in the latter half of the 1990s. Likewise, the number of prison
sentences for drug crime and the number of drug users in the prison population
continued to increase (Tham 2003).
Harm Reduction Measures in Sweden
As already mentioned, all user organizations in my international review pursue
one or more issues regarding harm reduction measures. In the Swedish context,
harm reduction has been an extremely controversial issue ever since it entered
the international debate in the 1980s. In Sweden the discussion has primarily
centered around two types of measures, maintenance treatment and needle
exchange programs.70
Maintenance Treatment in Sweden
The methadone maintenance treatment (MMT) concept reached Sweden as early
as 1966, but throughout the 1970s it was no more than a relatively small scale
trial, although this was belied by its high political profile. A few years into the
1970s, the Uppsala-based MMT project became embroiled in an increasingly
bitter political battle. The general opinion saw this as a risky and politically
suspect form of treatment (Johnson 2005).
Curiously enough, the resistance was led by RFHL, a client organization. In this
case the organization took an unusual – not to say deviant – stance from a user
perspective. The association’s standpoint can partly be explained by the negative
experience of a previous trial with legal prescription of drugs in the 1960s (see
Lenke & Olsson 1998). This trial had taken on great symbolic significance for
RFHL, serving as a cautionary tale of what may happen when working with less
ambitious goals than complete abstinence (Johnson 2005).
70
In an international perspective these measures tend to be classified as harm-reducing.
However, in Sweden both maintenance treatment and needle exchange programs have
always been tightly controlled programs with markedly social curative ambitions. One
principally important difference that should be highlighted though is that needle
exchange programs, as opposed to maintenance treatment, can not be regarded as a
treatment or rehabilitation measure.
146
The resistance to MMT led to the National Board of Health and Welfare, the
government agency in charge, not approving the treatment method until 1983.
From then on this treatment form became a regular health care component,
although confined to Uppsala. In the mid 1980s the previously hostile opinion of
MMT started to abate. At the same time RFHL also gradually began changing their
view on the issue, and today the association takes a more user-typical view of this
treatment method.
One strong contributing factor to this change was the fear of a major Aids
epidemic in Sweden. In fact, the Aids issue constitutes a watershed in the
Swedish methadone debate and can hardly be underestimated as the reason why
MMT was finally accepted and subsequently started spreading throughout the
country (Johnson 2005). In 1987 the National Board of Health and Welfare
allowed new MMT programs to start, and the following year a second program
was initiated in Stockholm. Another two were quickly initiated in Lund (1990)
and Malmö (1992), and in March 2004 a fifth MMT program was launched in
Gothenburg.
The general view among the foreign user organizations in my review is that – as
previously mentioned – MMT and other types of maintenance treatment should
be made available for those who wish to avail themselves of it. Ever since the
early 1970s, however, Sweden has had a centrally decided cap on the number of
patients who are simultaneously receiving MMT. In absolute numbers this
ceiling has gradually been increased, from 100 (1972) to 150 (1983) and so on,
up to 300 (1988) and 450 (1990). The 1990s saw a continuation of this
development, and in 2004 the ceiling was raised from 850 to 1,200 patients. In
relative terms this expansion has been more modest, however. According to
estimates of drug abuse, in 1979 just under 5 per cent of the opiate users were
given a place on this treatment program. In 1992 this figure was 9 per cent, and
in 1998 it had risen to just under 11 per cent (Johnson 2005).
The expansion has, in other words, been fairly slow, and in an international
perspective this is a fairly low percentage of the opiate users. From a user
perspective, however, the picture is not quite as gloomy if we also count the
users receiving buprenorphine (Subutex). This drug was approved by
Läkemedelsverket (The Swedish Medical Products Agency) in 1999, and has
become widespread, particularly at health centers. According to estimates by the
National Board of Health and Welfare, some 1,300 people received Subutex in
Sweden in 2003.
On 1 January 2005 new guidelines from the National Board of Health and
Welfare came into force regarding both methadone and Subutex (SOSFS 2004:8
M). The point of the new guidelines is to put methadone and Subutex on an
equal footing in a regulatory sense. The regulations for Subutex prescription has
consequently become clearer and stricter, while the MMT ceiling has finally
147
been lifted – changes long overdue from a user perspective. It still remains to be
seen, however, what consequences the new guidelines will have in terms of
access to these treatment programs.
Finally, it is worth noting that the Swedish MMT program has been the focal
point for much of the user mobilization that has taken place in Sweden in recent
years. The Swedish Users Union, for instance, was founded as a pressure group
for methadone patients.
Swedish Needle Exchange Programs
One of the main arguments against MMT in the 1970s and 1980s was that it ran the
risk of sending a ‘conflicting message’ to the users about society’s views on drugs.
The same argument has been the most important one for the opponents of needle
exchange programs ever since the start in 1986–87. These programs, based in
Malmö and Lund, came about as an emergency measure in order to stop the HIV
virus from spreading among the users. Ever since the start the programs have
been tolerated, but only just, and are seen as limited trials. They have enjoyed
strong local support throughout, but in the national debate the negative views
have dominated. Since the early 1990s RFHL have been one of the supporters of
needle exchanges, although the internal decision to speak out in favor of it was
not unanimous.
For a long time the future of these programs were in doubt, but in recent times
public opinion has started to change also on the needle exchange issue. At the
time of writing the Swedish Parliament has just decided to make the existing
needle exchange programs permanent and integrate them in the regular treatment
framework for infectious diseases, and to allow new programs. However,
according to this decision any new programs should be subject to permission
from the National Board of Health and Welfare, and in the evaluation process
access to detoxification and other areas of the addiction treatment be taken into
account.71
Health Care and Information Issues – Swedish Experiences from a
User Perspective
71
This requirement – which must be seen as a way of allaying the fears of opponents of
needle exchanges that society would prioritize cheaper harm reduction measures at the
expense of more resource intensive forms of drug addiction treatment – has been
criticized by the users. In their comment on a preparatory report, RFHL expressed the
opinion that the proposal runs the risk of giving users in local councils with poorly
developed treatment facilities a double whammy by denying them access both to regular
treatment and needle exchange programs.
148
When it comes to treatment and information issues, since the 1980s public drug
policy measures in Sweden have almost exclusively centered around the
infectious diseases HIV and, to a lesser extent, hepatitis. In the mid 1980s the
government agency Aidsdelegationen (The Aids Delegation) instigated a
campaign whereby social workers were encouraged to seek out users and inform
them about the risks of HIV/Aids and induce them to seek treatment (Johnson
2005). The primary responsibility for this practice, however, rested – here, as in
later campaigns of this type – with local and county councils. When it was clear
that the risk for a widespread Aids epidemic among Swedish drug users had been
fended off, the 1990s saw a reduction in the resources alloted for information
campaigns.
In Sweden the debate about access to health care often has centered on the fact
that many users have an insufficient interface to civic society. The debate often
resurfaces in connection with the needle exchange programs in Malmö and Lund
in the south of Sweden, with the supporters pointing to these programs as a
unique resource for upholding the contacts with the users. They have given users
in need better access to other health care institutions as well as the social
services. The RFHL position on the needle exchanges for a long time has been
wholly positive, and the same can be said for the Swedish Users Union since its
foundation in 2002. The view of the authorities on these programs was discussed
in the previous section.
Prominent issues in the international user debate, such as the opportunities for
spreading information on safer drug use and how users can protect themselves
against overdoses and the like, are filed under ‘harm reduction measures’ in
Sweden and thus actively discouraged. Some attempts at moving such issues
onto the agenda have been made by users, but to hardly any avail.
Substantial Influence – Concluding Remarks
In conclusion it must be said that the Swedish drug policy in the 1970s was
relatively user oriented. A major expansion of the drug addiction framework had
been initiated, the control policy was restrained in relation to the users and on
both the compulsory treatment issue and the methadone issue the official line
coincided with the opinion of the users, at least as manifested by the client
organization RFHL. The RFHL view on the methadone issue, however, was not
representative or typical of users in an international perspective.
From the users’ point of view, the positive development in drug addiction
treatment – except for the issue of compulsory treatment – continued in the
1980s. The expansion continued throughout almost the entire decade, from 1985
onwards fueled by the great fear of an Aids epidemic among the users. The Aids
issue meant that, on the whole, traditional user interests were accommodated to an
149
increasing degree, although for reasons other than specific user interests. The
general view of methadone maintenance treatment (MMT) turned more positive and
two needle exchange trials were launched in southern Sweden. Towards the end of
the 1980s RFHL too began changing their position on these issues, and in the 1990s
they totally embraced the conventional user view.
The control policy, however, turned ever less user friendly. On the whole the
repressive development from around 1980 until the criminalization acts of 1988
and 1993 can only be seen as devastating from the users’ point of view. In an
international perspective, however, the Swedish control policy can not be
considered out and out extreme, even though many European countries have a
more liberal legislation (Lenke & Olsson 2002).
The 1990s saw a further reinforcement of the control policy measures, albeit at a
more modest pace than in the period from 1980 to 1993. The greatest change
during this period instead took place in the treatment sector, where the economic
hardships caused a drastic decline. Treatment resources remained at the same
level or decreased slightly, while drug use increased dramatically. Even without
adopting a pronounced user perspective this development can not be considered
anything but sad.
It should be pointed out though that in recent years at least one positive sign can be
discerned: access to methadone- and Subutex-based maintenance treatment
programs have increased slightly while the rules and regulations surrounding these
programs have become more flexible. If we turn to the needle exchange issue, the
future has brightened considerably here as well. Good news for the users, but
whether these positive developments prove to be the turning of tide or just a passing
whim remains to be seen, however.
User Influence on Swedish Drug Policy
In this study I have investigated the influence of Swedish drug users over public
drug policy in the period 1965–2004. I have been able to establish that their
influence has been extremely limited in recent decades, and, as far as can be
judged, this influence seems to have diminished over time.
The picture of the development of user influence is similar both in terms of
processual influence (the degree and the way in which users have been allowed
to participate and influence drug policy making), and in terms of substantial
influence (the degree to which the drug policy has managed to produce results
that are in the users own interests).
In order to study the processual influence I have reviewed the influence users
exerted over public drug policy inquiries. Assuming that participation in such
150
inquiries is an acceptable measure of processual influence, the only possible
conclusion is that the users, since the inquiry by the Committee for the
Treatment of Drug Addiction, have had a very limited processual influence over
drug policy. What influence can be traced has taken the form of participation in
the consultation and referral process, two forms of influence that often take on a
more or less ritual character without guaranteeing any real influence.
In terms of substance the public drug policy was relatively user oriented in the
1970s. The control policy focused on the drug trade, and kept a low profile in
connection with individual users. A major expansion of the drug addiction
treatment framework had been initiated, and on important user issues – such as
compulsory treatment, criminalization of personal use and methadone
maintenance treatment (MMT) – the drug policy on the whole coincided with the
general user opinion, at least as expressed by RFHL. During the 1980s the policy
gradually turned less user oriented as the control policy was reinforced, the
powers to order compulsory treatment were increased and personal drug use was
criminalized. In the 1990s public cutbacks hit the treatment framework, while the
number of users rose rapidly. This leads us to conclude that the public drug policy
in Sweden has become less user oriented over time also in terms of substance. In
light of this, the mobilization of drug users in an organization such as the
Swedish Users Union does not appear to be a result of the authorities requesting
their participation, but rather a symptom of the users feeling forgotten or
neglected.
Causal connections are not directly observable in the social sciences, and in any
event it is not possible from a study like this to draw any definite conclusions as
to the connection between processual and substantial influence. However, a
reasonable hypothesis appears to be that a high degree of processual influence
tends to lead to greater substantial influence. This study does not provide any
reasons to reject this hypothesis. Consequently it can not be ruled out that the
relatively high degree of user orientation in the public drug policy at the end of
the 1960s and in the first half of 1970s actually was a result of the influence
exerted by RFHL within the important inquiry by the Committee for the
Treatment of Drug Addiction and in other ways.
The right of drug users to exert an influence over public drug policy has never
been formally expressed in Sweden. From time to time, especially in the 1970s,
RFHL have been regarded as an important party to the discussions worth
listening to, but only in the capacity of client organization, not as an organization
for drug users. Correspondingly, the fact that SBF nowadays is an official
referral body should be interpreted as recognition of the organization functioning
as a patient organization for maintenance treatment patients.
In conclusion, the result of this study must be regarded as pretty dismal for
anyone arguing for a more user oriented drug policy. Nonetheless, a small degree
151
of user influence over public drug policy does not necessarily mean that the user
influence has been limited in other spheres of influence. It does not seem
unreasonable to think that individual users could exert a certain amount of
influence over the day-to-day runnings in the drug addiction treatment
framework, for instance at local council level. That, however, will have to be the
subject for another study!
Translation: Ola Winfridsson
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[Drug users, social services, coercion]. Stockholm: Allmänna förlaget.
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treatment – the darker side of the welfare story]. Alkohol och narkotika, 95 (6): 96–105.
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Carlssons.
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Tham, Henrik (1998): Swedish Drug Policy: A Successful Model? European Journal of
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URLs to User Organizations:
AVIL (Australia) http://www.aivl.org.au/default.asp
Brugerforeningen (Denmark) http://www.brugerforeningen.dk/bfny.nsf
Brukerforeningen Tønsberg (Norway) http://www.brukerforeningen.no/
Jes-Bielefeld e.V. (Germany) http://www.junkienetz.de/
Junkie Bund (Germany) http://www.junkiebund.de/index.htm
MDHG (The Netherlands) http://www.mdhg.nl/
Springfield Users’ Council (USA) http://springfielduserscouncil.org/
Svenska Brukarföreningen (Sweden) http://www.brukarforeningen.com/
The Alliance (Great Britain) http://www.m-alliance.org.uk/
UNDUN (Canada) http://www.freewebs.com/undun/index.htm
VANDU (Canada) http://www.vandu.org/
154
The Consumer, the Weak, the Sick, and
the Innocent
– Constructions of ‘the User’ by the Swedish Users
Union72
Jessica Palm
Introduction
Drug users are often described as a socially marginalised group in Swedish
society (Lander et al. 2002; Svensson & Kristiansen 2004, Fondén et al. 2003).
This condition is sometimes blamed on the country’s restrictive drug policy
(Lander et al. 2002). Although there are large number of associations and nongovernmental organisations in Sweden, only very few organisations have been
primarily aimed at drug users (see the article by Laanemets in this publication).
There are, however, several associations for former drug users and parents of
drug users, many of which have been influential in the drug policy debate and
some of which claim to advocate the interests of drug users.
The focus of this paper is on a relatively new association, i.e. the Swedish Users
Union (Svenska Brukarföreningen – SBF). The SBF was founded in 2002 in
Stockholm as an interest organisation for opiate users with or without
substitution treatment (methadone or buprenorphine, which in Sweden is called
Subutex73). It is the first and only association in Sweden whose board consists of
active users of opiates (including methadone and Subutex). Before the SBF, drug
users in Sweden had lacked a public voice. The SBF is committed to defending
the interests of drug users among others in relation to the caregivers in charge of
substitution treatment. According to Berne Stålenkrantz74, head of the union
since it was founded, the main background and motivation for the establishment
of the SBF came from the difficulties in obtaining methadone and the problems
in the Stockholm methadone programme: its high levels of control, strict
demands on users, and punitive actions. Furthermore, no one was available to
advocate the patients’ interests.
72
73
74
The article has been reviewed by two referees.
Subutex is the term used by the SBF for buprenorphine and therefore used in this article.
Chairman of the SBF board, Berne Stålenkrantz, was interviewed on 4 February 2005 to
gain an overview of the union’s history so far.
155
The first discussions on organising drug users were held between Stålenkrantz
and Björn Hjerdin from the Stockholm section of the National Association for
Aid to People Addictive to Drugs and Pharmaceuticals (RFHL)75 in the spring of
2002. The RFHL made office facilities available to Stålenkrantz and in October
2002 a board was appointed and statuses formulated at a meeting with 15 users
of heroin or substitution treatment. According to these statutes all decisionmaking was restricted to drug users on the board, which consisted of 12 persons
appointed at an annual meeting. The SBF’s mission is to advocate the interests
of patients within the treatment system. It wants to see a policy shift from zero
tolerance (including substitutes) to harm reduction, primarily to reduce drugrelated deaths. Another aim of the union is to counter stigmatisation:
There is a lot of prejudice against our members, and the association will be
working to eliminate that prejudice. (Application to the National Board of
Health and Welfare 2005)
Within just 10 months, the association had attracted 500 members. Some
problems arose early on, partly of a financial character, but there were also
internal conflicts regarding the SBF’s political direction 76. By early 2006, the
union had around 1,000 user members and local associations had been
established in Malmö, Lund, Sörmland, Örebro, Stockholm and Sundsvall.
Moreover, there are local user representatives in Umeå, Borlänge and Kalmar.
There is also a section for relatives, with around 300 members. The SBF is no
longer attached to RFHL and it has moved out of the RFHL’s premises.
The SBF is an interesting association, for several reasons. Prior to the founding
of the SBF, most actors on the Swedish drug policy arena were non-users and exusers. Furthermore, the union has grown very rapidly and there are early
indications that it has been recognized as an actor within the drug policy debate77
and among caregivers78. The SBF can be seen as both a product of contemporary
discourses and an actor that could come to influence the dominant drug policy
discourse.
This article uses discourse analysis to explore how the SBF constructs the ‘user’
in its official texts, as seen in the light of the official Swedish drug policy
discourse. Swedish drug policy has been described as highly restrictive and
75
76
77
78
The most prominent client organisation for drug users to date, the RFHL, was founded
in 1965. The organisation emerged as a reaction to the repressive and restrictive
measures imposed in society against drug users. See also the articles by Leili Laanemets
and Björn Johnson in this publication for more information on the RFHL’s ideology and
establishment.
Views differed mainly on how liberal a stance the SBF should/could take in the public
drug policy debate.
The Ministry of Health and Social Affairs and the National Board of Health and Welfare
have asked the SBF to give its opinion on public reports on drug policy issues.
For purposes of quality control a council was set up with representatives of both the SBF
and caregivers.
156
moralising in its attitude towards drug users, and the SBF may be understood as
a reaction against this approach. The SBF’s construction of the ‘user’ is central
in this respect. The SBF combines different constructions in a novel way, and
this new combination can be seen as representing an “official SBF discourse”.
The strategy chosen is interesting in that it sheds light both on the perspective of
the dominant Swedish drug policy discourse and on what other discourses are
available, what can (and cannot) be expressed within the dominant drug debate
and how a reaction on the part of users can be formed.
Swedish Drug Policy
To gain an understanding of the context within which the SBF has emerged, we
need to begin by looking briefly at official Swedish drug policy and its
construction of the ‘user’.79
Swedish drug policy is traditionally characterised by a restrictive attitude, the
ultimate goal being to completely eradicate drug use (SOU 2000). The three
cornerstones of this policy have been treatment, prevention and control.
However, it was not until the 1960s that drug use was established as a social
problem, in what Johnson (2003) calls a collective definition process.
Over the years, right-wing and left-wing parties in Sweden have been competing
with one another over who is the toughest on drugs – and consequently the
controls and restrictions have continued to expand and deepen (Laursen 2001;
Tham 2003). On the other hand since the turn of the century there have been
growing signs of some movement towards harm reduction measures. This softer
approach is reflected in new nationwide guidelines for needle exchange80, the
spread of substitution treatment with Subutex, increased availability of
methadone treatment and a rather more critical debate about “the Swedish
approach”.81 However, this tendency should not be overestimated. Swedish drug
policy and its goals still stand (SOU 2000), and it appears unlikely that the
existing control measures will be relaxed. Tham (2005) thus interprets the
proposal for a national syringe exchange programme as part of a public health
perspective rather than a human rights perspective. Further, maintenance
treatment is still seen as a temporary solution which ultimately should lead to
complete rehabilitation and abstinence (Tham 2005). A long-standing argument
against methadone treatment is that the “patient” still remains a drug user
(Johnson 2003). Recent research has described the public health approach as less
79
80
81
See the articles by Leili Laanemets and Björn Johnson in this publication for a historical
description of Swedish drug policy.
Needle exchange programmes have only been available in Malmö/Lund, and even here
their operation has been disputed.
A critical investigative TV programme on substitution treatment, for example, was aired
on Swedish television on 17 October 2005.
157
ideological and more pragmatic than the human rights approach, thus facilitating
a combination of harm reduction measures with a restrictive policy (Hurme
2002; Hakkarainen & Tigerstedt 2003). Here a distinction needs to be made
between harm reduction measures and human rights ideology (Hurme 2002). The
reluctance to use the term harm reduction in Swedish drug policy is probably due
to the ideological resistance against drug use and regarding drug users and their
civil rights as accepted parts of society. Nonetheless it is a reasonable
interpretation of the growing reliance on harm reduction measures that a public
health approach as a pragmatic solution to problems due to drug use is being
combined with a restrictive policy still aiming at a drug-free society.
In 2002, the Ministry of Health and Social Affairs set up a new agency called
Mobilizing against Drugs (MOB) in a bid to intensify the struggle against drugs.
MOB’s action plan includes steps to cut the supply of drugs, reduce the number
of youths experimenting with drugs, and to increase the number of people
receiving help with quitting drugs (MOB 2004). The launch of MOB was
effectively a way of demonstrating the government’s determination in the face of
the drug problem at a time when research pointed at an increase in drug-related
deaths (Olsson 2001) and more widespread drug use among young people (CAN
& FHI 2000). This effort has also shown some interest in the perspectives of
drug users.82 Furthermore, the National Board of Health and Welfare has on
various occasions taken notice of the users of health services. User organisations
have been invited to take part in reference groups and give their views on current
treatment practices. Indeed such expressions as “user influence” and “user
interests” are now being heard more and more often.
Method and Material
Theoretical Point of Departure
In this section my intention is to sketch the background against which the results
of this study will be analysed. This study is a discourse analysis. Winther
Jørgensen and Phillips (2000) provide the following useful description of
discourse as defined by Laclau and Mouffe, whose poststructuralist perspective 83
is at the core of my theoretical point of departure:
82
83
MOB and the National Board of Health and Welfare have commissioned a study on
drug users’ experiences of the drug treatment system (Svensson & Kristiansen 2004),
and there have been discussions on the subject between the SBF and MOB.
Laclau and Mouffe can be seen as poststructuralists in the sense that they consider
everything to be language and thus discourse. It follows that there is always more than
one truth that can be described.
158
A discourse is conceived as a fixation of meaning within a specific domain. All
signs in a discourse are moments; knots in a fishing net, and their meaning is
fixed through their specific way of being different from each other (differential
positions).
According to the theory of Laclau and Mouffe (1985), nodal positions are the
central signs or “privileged discursive points” of a discourse around which other
signs are organised and given meaning. Alternative meanings are constantly
threatening to destabilise the fixation of the fishing net in the discourse, and
these alternative meanings are relegated to what Laclau and Mouffe call the field
of discursivity. This field holds all the alternative meanings that a discourse is
doing its best to keep at bay. In the Swedish official position on drugs, for
example, “stimulant” in the sense of “drug” is referred to the field of discursivity
to prevent any positive associations being connected to the word. At the same
time, “stimulant” is constantly threatening to destabilise the closure/net fixation,
or the view of drugs as something dangerous and threatening (could be seen as a
nodal position). All moments are potentially ambiguous. Concrete articulations
reproduce or question the prevailing discourses by fixating meanings in a
particular way. According to Laclau and Mouffe (1985), a constant battle is
going on within the field about how the structure should be organised (in the
fishing net/fixation), which discourses should rule and which meaning should be
given to particular signs.
One of the key concepts in the theory of Laclau and Mouffe (1985) is that of
‘hegemony’, which they adopt from Antonio Gramsci. Hegemony consists of the
processes that create people’s consciousness, a kind of disciplining where the
power tool is meaning-making. Hegemony implies that power structures are
neutralised and taken for granted. A kind of consensus is in place that hides any
alternative meanings. The processes are not guided solely by economic power or
economic struggles, but they can also be influenced by opinion-forming
strategies and resistance to existing conditions. In the same vein, Foucault (1982)
states that power is not something that is imposed on us from above, but rather it
is constantly reproduced by each and every one of us. Official Swedish drug
policy discourse, with its scarcity of opposition and alternative understandings,
is a good example of hegemony.
Starting from the theory of Laclau and Mouffe, the following questions can be
posed in order to try and understand how the SBF constructs the user and the
drug policy discourse that they use: How does the users union threaten the
structure of other, dominant discourses? What meanings do they establish, what
meanings are withheld? On what discourses are the SBF’s articulations built,
what discourses do they reproduce? How does the SBF rephrase and question a
discourse by redefining its moments? What signs have a privileged status (i.e.,
are nodal positions) and how are they defined in relation to other signs? What
construction of meaning is the struggle about? These questions should be
understood not so much as research questions, but instead as tools of analysis.
159
Material
The discursive practices that I want to study here are those expressed in written
text, even though the SBF obviously also uses other discursive practices such as
oral communication. These texts have the benefit of being limited to what the
SBF wants to communicate publicly. For reasons of research ethics, the
association’s internal communication is excluded from the analysis. Included are
all the public texts produced by the SBF since its establishment in 2002 until the
beginning of 2005. Most of these texts have been written by a handful of
persons. All texts published in the name of the SBF are read by at least the chair
and one other person. The board also has active discussions about articles, other
texts, as well as the association’s political agenda. All these texts analysed are
listed in Appendix 1, and they can be divided into five categories:
■ Debate articles and press releases
■ Newsletters84
■ Informative texts (folders and website)
■ Responses to political queries
■ Applications for funding
These texts were all treated in the same way in the analysis. SBF newsletters and
texts on the SBF website include personal accounts of life events, mostly
maltreatment, written by individual members. Even though they might shed
useful light on treatment, I have chosen to exclude these stories from the analysis
since they do not represent the SBF’s views or their way of expressing
themselves. The same goes for information about medication and treatment
provided for SBF members on the association’s website; these texts do not
contribute to the attainment of the aim of the study. Texts about views on
treatment and medication written in the name of the SBF are, however, included
in the study.
Procedure
The research was carried out in several steps. To begin with, the texts were read
with the aim of finding different descriptions of the “user”. These descriptions
were classified initially into three categories/themes/positions: “the consumer”,
84
According to the SBF, its first newsletter (which was no more than a few sentences) has
disappeared; it is therefore excluded from the analysis. Newsletter 5 is also missing
because it was never written. What is now newsletter 6 should have been newsletter 5 –
a mislabelling.
160
“the weak” and “the sick”. The texts were then re-examined in closer detail
against the background of this run-through and the aim of the study in order to
form a picture of what was written on these central variations of “the user”. “The
weak” and “the sick” were particularly prominent representations to me in many
of the texts, especially in debate articles and press releases, and “the consumer”
was central in my search for different positions because of my expectations
regarding the name of the organisation. Later, a fourth theme was added under
the heading of “the innocent” as I found that it could be distinguished from “the
weak” and that it was central to the SBF’s opposition to the dominant drug
policy, which in itself is essential in the SBF’s texts. Parallels are also drawn to
the first three of four possible perspectives (human rights, diseases, public
health, criminal) on harm reduction outlined by Hurme (2002). When it comes to
studying perceptions of what is conceived as “normal”, it is sometimes easier to
define what a term does not mean (see Mattsson 2005), and what “the user” is
not is clear in the opposition to the dominant drug policy. Finally, quotes were
chosen to reflect what is expressed in the texts within each theme, even though
the concern in some cases is with specific choices of wordings. It is obviously
not possible to clearly separate the different themes from one another, and what
is said on one theme can also tell us something about another theme.
Since some phenomena are not directly expressed in the texts, I also use certain
linguistic tools to try and understand the SBF’s viewpoint regarding a certain
topic. Roger Fowler (1991) provides a useful description of analytical tools used
within critical linguistics. Here, I concentrate on how “the user” is described in
terms of active and passive, and on whether agents are visible or of no interest.
Finally, I examine Swedish drug policy to discuss possible descriptions of “the
user” that are not expressed in the SBF’s texts. Huckin (2002) brings up different
forms of textual silence, concentrating most particularly on manipulative silence.
Sometimes what is not said is more important than what is said for achieving
one’s goals. Manipulative silence is about the encoder of a message consciously
withholding questions that are important for the issue at stake, in order to
mislead and gain an advantage (Huckin 2002). My interest is in the possible
ways of describing “the user” that are missing in the SBF’s texts.
In the excerpts below, issues of particular interest are marked in italics – these
italics did not appear in the original texts. All original SBF texts are in Swedish
and have been translated by the author. Inevitably, some nuances will have been
lost in the translation process since two languages might not have the exact same
word for the same meaning. Further, I use double quotation marks for quotes and
for indicating the meaning of a term (a definition or a concept), and single
quotation marks for referring to a word/term (also called a ‘sign’) (see Bergström
& Boreus 2000, 7–8). Having said that, it is in practice difficult to separate a
sign from its meaning. Meanings are interwoven in signs (see the discussion by
Spivak on the deconstruction of the dualism signifier/signified by Derrida 1998).
161
Results
“The Consumer”
The first point I want to raise is the term ‘user’, which is used both by the SBF
and by other drug policy actors such as the National Board of Health and
Welfare and Mobilizing against Drugs. In the case of the SBF, it is clear that it
refers to “consumers of drugs”, and mainly of opiates, while in other contexts
‘user’ is understood as “treatment consumer”. In the case of “consumer of
drugs”, the use of the term ‘user’ can be understood as a reaction to the term
‘misuser’ or abuser, which is often used to refer to all users of drugs (see above).
In Swedish, the most common word for ‘user’ is ‘användare’, but the word for
‘misuser’ is ‘missbrukare’, incorporating the less frequently used term ‘brukare’,
which also means ‘user’. By using the word ‘brukare’ instead of ‘användare’, the
SBF position themselves against those who wish to characterise all use of drugs
as “misuse”. It is also clear from the following quote that the SBF sees the
concept of ‘misuser’ as problematic:
… the objectifying and grossly generalising categorisation “misuser”. (Response
to political query on compulsory treatment 27 June 2004)
The use of the term ‘user’ in association with treatment, as in the rhetoric of
official agencies, is a relatively new phenomenon. Previously the terms ‘client’
(in social services) or ‘patient’ (in health care) were used to denote individuals
receiving care or treatment for substance problems. As opposed to
‘client/patient’, the term ‘user’ emanates from a verb, ‘to use’, and thus it
conjures up connotations of a more active subject than ‘client/patient’, who is
thought of as a passive object of interventions by others around them, such as
doctors or social workers (see Asmussen 2003). The following quote is an
example of the SBF’s view of ‘the user’ as someone who is capable of assessing
her/his own needs of treatment and thus of being an active “treatment
consumer”:
The law on compulsory treatment seems to be premised on the assumption that
persons who are drug dependent do not understand what is in their best interests
and are unable to assess their own needs. We at the Users Union speak from our
own experience and can assure that this (assumption) is not true. We are fullfledged experts on our own problems. (Response to political query on
compulsory treatment 27 June 2004)
The more frequent use of both ‘user’ and ‘consumer’ to refer to individuals in
treatment can be understood with the help of Fairclough’s expression
162
“marketization of discourse” (1992). Fairclough is implying that a market
discourse is colonialising other discourses. This can be interpreted as a move
away from a welfare discourse where services are offered to
citizens/patients/clients towards a new liberal consumption discourse where
commodities are chosen/consumed by/sold to consumers/users.85 ‘The user’ is
implicitly expected to be more active and to assume greater responsibility for
her/his care, which can be interpreted as individualisation. Instead of the
collective looking out for the individual, the individual has to take personal
responsibility and look out for her/himself. If things do not work out well for the
individual, s/he has only her/himself to blame.
The SBF’s comments on competition within the treatment system can also be
seen as part of a consumption discourse. Competition, the SBF says, would give
“the opiate dependent person better access to individually adapted treatment”
(Press release 30 April 2004).
We hope that the new guidelines will make it easier for private care providers to
enter this treatment area, which today is heavily politicised. (Response to
political query on Subutex-methadone 27 May 2004)
The SBF also admits the difficulty of defining its target group of “heroin
addicts”, and instead locates the definition in the common interests of users that
it wants to make visible (SBF website, text written 11 June 2003). The common
interests brought up in the text concern pharmacological treatment alternatives,
methadone and Subutex; placing important decisions about oneself in the hands
of others; failed attempts to gain influence over personal treatment; and the
experience of being subjected to arbitrary and repressive measures. On several
occasions, however, expressions such as ‘user’, ‘user part’ and ‘user perspective’
(Application 26 June to the County Council (Landstinget), Appendix 1) are used
without further definitions of these parts, perspectives and interests.
The silence surrounding a given subject may be equally as interesting to explore
as the explicit (see Huckin 2002). One meaning absent in the texts that is
relevant to understanding the limits of the construction of ‘the user’ as “the
consumer”, is that of individuals who are not interested in quitting drugs –
individuals who say they are doing drugs out of their own free choice because
they feel they get something out of it. Drug users who are not interested in
treatment, no matter how it is framed, are given no attention. The views that this
group might have – that they should be allowed to do drugs if they want to – are
therefore absent. The image of a strong, actively choosing “user” that one might
have expected to find, considering the use of the term ‘user’ as a reaction against
the use of ‘misuser’, is thus missing. I interpret this absence as an expression of a
manipulative silence, since this image of “the user” could potentially destroy the
85
Järvinen & Mik-Meyer (2003) consider this an illusion, since the views of staff members
are nevertheless always superior to the client’s.
163
chances of the SBF taking part in the Swedish debate where the dominant
understanding is that any type of drug use is a problem that should be dealt with.
In sum, ‘the user’ as “the consumer” is visible in the texts mainly as a capable,
choosing consumer of treatment, but this is not among the most dominant userpositions. ‘The user’ as “the consumer” can be considered equivalent to the
subject position focused on human rights and the equality of drug users in
Hurme’s (2002) four perspectives on harm reduction, referring to an active and
equal subject that should be treated with the same respect as any other citizen.
“The Weak”
It is difficult to find more elaborated descriptions of ‘the user’. In fact, the term
‘user’ is not used particularly frequently. Instead, the texts prefer to use words
like ‘drug dependent’, ‘junky’, ‘heroinist’, ‘patient’, ‘persons with drug
problems’ (target group according to the Application to the National Board of
Health and Welfare 2005) and even ‘misuser’ (see e.g. Response to political
query on knowledge overview concerning substitution treatment from the
National Board of Health and Welfare, November 2002). The absence of ‘the
user’ may well be a tactic to appeal to those recipients of the texts who might be
more familiar with these expressions and who themselves use them frequently,
but it may also be understood as a means to serve the SBF’s own purposes.
Interestingly, the most common description of ‘the user’ is one of a deprived,
marginalised, sick and exposed person “on the bottom of society”. On some
occasions there are even faint suggestions that ‘the user’ is not really alive at all,
or rather needs to “come back to life again” (Response to political query on
knowledge overview concerning substitution treatment from the National Board
of Health and Welfare, November 2002). For “weak” individuals, descriptions
such as ‘drug dependent’, ‘misuser’ and ‘patient’ are better suited than ‘user’,
which, as mentioned above, is a term more associated with the image of actively
choosing individuals. At the same time, the description of ‘the user’ as “weak” is
coupled with the failure of others, even though these “others” are largely kept
invisible. For instance, in the third quote below, it is unclear who is placing the
weak outside, and expressions such as ‘society’ and ‘the public’ are not defined
further. This absence of a defined agent could be interpreted as a conscious
strategy, a kind of manipulative silence (Huckin 2002) in order to relieve “the
user” from responsibility (see “The Innocent” below). However, it could also be
seen as a presuppositional silence, where the sender of the message takes for
granted that the receiver understands what is meant.
… the fear and insecurity of the public contributes to our isolation. (SBF
website, text written 11 June 2003)
… many of the weakest are being left outside.” (Newsletter 6)
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In reality we are talking about social and psychological problems that cannot be
punished away. On the contrary, this punitive approach only intensifies the social
and psychological problems. Without the solidarity and understanding of society,
it is almost impossible to break out of the problematic use of drugs. (Newsletter
6)
We find an opposite to the view of ‘the users’ as weak if we look at how the SBF
describes its organisation, which consists of “users”. In the quote below, there is
nothing to imply that the SBF is weak. Instead, the SBF is described as active
and supportive. However, the description offered of the SBF also strengthens the
view of ‘the user’ as weak.
The Swedish Users Union sees, hears & acts! (Newsletter 6)
In the next quote, the distinction between “the users” or “the comrades” and the
SBF is clear.86 “The users” are portrayed as weak and the SBF as strong. The use
of ‘we’ in the texts sometimes refers to “us the users”, sometimes to “us active in
the SBF”. The quote below is an example of ‘we’ referring to the SBF.
Many of our comrades have difficulties making themselves heard in their
contacts with the authorities, social services, the justice system, care providers
and others and need assistance and knowledge, and in this we have been able to
help. (SBF website, text written 11 June 2003)
The following quote, then, is an example of ’we’ referring to “we, the users”. It
portrays the SBF as activists (a term that is also used by the SBF, Newsletter 2)
fighting against the power structure.
Remember that together we are strong, alone we are weak against the system.
(Newsletter 2)
Descriptions of ‘the user’ as weak and in need of help from the authorities are
relatively frequent in the texts. The position is in line with the public health
perspective on harm reduction as presented by Hurme (2002). In the public
health perspective, the drug user is mostly visible as a recipient of services.
“The Sick”
The terms ‘heroin dependence’ and ‘heroinism’ appear in several texts, implying
a disease perspective. ‘Dependence’ is a medical term, and within the medical
profession various tools have been developed for the measurement of addictions
to substances and activities (i.e. gambling) (Janca et al. 1994). Impairment or
loss of control is a significant feature of these medical characterisations of
86
It is, however, also stated that those active in the union should not be specialists, but
rather communicate the members’ views (Covering letter for Application to the Social
Services Administration, 10 November 2004).
165
“dependence”. In the medical literature, dependence also refers to biological
processes and certain conditions in the brain. This is not, however, what is
usually measured when someone is screened for ‘dependence’, and social
scientists have criticised the medical discourse for creating a category which is
not easy to distinguish and which risks stigmatising those categorised as
dependent (Blackwell 1988). ‘Heroinism’, on the other hand, a term that is not
frequently used in Sweden, sounds equivalent to ‘alcoholism’, which is an older
term than ‘dependence’ in Swedish and nowadays associated with the alcoholism
movement87 (AA ideology) 88. The AA ideology is also a kind of disease
perspective. Alcoholism is described as an incurable disease where the sufferer
needs to realize she/he will always be sick and has to abstain from alcohol. The
difference is that the AA sees other than medical solutions to the problem
(Gusfield 1996).
There are also other similarities between the alcoholism movement and the SBF.
In its early days the alcoholism movement considered it important to construct
the alcohol problem as a disease; this was necessary in order to distance itself
from the prevailing moral discourse where the drinker was seen as bad and
weak-willed and should be punished rather than treated (Levine 1978; Blackwell
1988). The disease concept meant that responsibility for the problem could no
longer be placed on the individual, since it was not the individuals’ fault that
she/he had caught the disease. 89 Similarly, I interpret the SBF’s construction of
the user as sick as a means of opposing the moralisation to which drug users are
confronted (see also “The Innocent” below).
Drug treatment should be guided by the same ethical rules that are applied to the
treatment of all other kinds of diseases. (SBF website)
Patients with substitution treatment – methadone or Subutex – are dependent on
a prescribed medication for the sake of their health. (Article in Södermanlands
Nyheter 22 May 2003)
Needle exchange is a recurring theme in several debate articles, press releases
and newsletters. The SBF apparently takes a positive stance on needle exchange,
but it is critical of the proposal put forward by the National Board of Health and
Welfare which according to the SBF places too high demands on municipalities
and counties, effectively making exchange programmes impossible. In its texts,
the SBF reconstructs the meaning of needle exchange:
87
88
89
In the United States where the AA originated, it was the alcoholism movement that
spread the term and the word about alcoholism, whereas AA members, anonymous as
they were, were less active in the debate (Room 1983).
The term “alcoholism” was introduced in Sweden by a doctor, Magnus Huss, in 1849.
At that time, though, it referred mostly to the chronic physical effects of alcohol
consumption.
According to Levine (1978) and Blackwell (1988), the disease perspective just meant a
new way of controlling people with roots in the temperance movement.
166
Clean needles for injecting misusers are solely a health matter. (Newsletter 6)
It is sick people who are being refused access to detoxification because the social
services say no to aftercare, and who often lack the capacities to take part in
ambitious programmes. The government’s suggestion for needle exchange is
designed for an elite among the drug dependent. (Newsletter 6)
Substitution treatment seems to be the main focal theme for the SBF. The SBF
also sees treatment as moralising and wishes to construct methadone and
Subutex as medication, which means taking up a position against those who
define these substances as drugs comparable to heroin, and think that
substitution treatment is just about exchanging one drug for another.
The above-mentioned juxtaposition between a social and a medical
understanding of the drug problem continues to persist in many places. It is
often social workers who put up obstacles to people who want to get into
methadone or Subutex treatment. (Newsletter 6)
To have or to achieve more control over the prescription of these substances
(Subutex) seems far more important than giving adequate and real help to the
persons dependent on drugs. (Press release 4 March 2004, following an MOB
conference on over-prescription90)
The first of the two quotes above indicates that the SBF prefers a medical
understanding over a social one, even though the quote below (and the third
quote in the section “The Weak”) shows that it also adopts a social perspective −
although it is not clear in what specific way the problem is seen as social.
Further, the last quote in this section shows that an individual-oriented approach
is preferred to a collective one.
To decriminalise personal use. Argument: by criminalising drug use, society is
saying that it is mainly the responsibility of the police, the criminal justice and
the prison systems and not a social problem. (Newsletter 6)
We turn against the collective perspective that is applied when the treatment
system describes our problems and needs. (Newsletter 6)
‘The user’ as sick is a common position and corresponds to the disease
perspective of harm reduction outlined by Hurme (2002). This perspective views
drug dependence as a disease of the individual and is aimed at curing the
“misuser from dependency and making his life as normal as possible” (Hurme
2002).
“The Innocent”
90
“Over-prescription” means that too much medication is prescribed and that there is a
“black market” for prescribed substances.
167
Another construction of ‘the user’ that is not far removed from notions of ‘the
user’ as weak and sick is the construction of “the innocent”. It does , however,
need to be separated from the two others since it appears as a reaction to the
description in the dominant drug policy discourse of ‘the user’ as “the guilty” or
“responsible”
The texts do not say very much about how individuals started using drugs, but
the construction of ”the user” as ”innocent” is reinforced with the repeated use
of such expressions as “end up in”, “got stuck in”, “driven/forced into” or “fell
upon” (see my italics in the quotes below). These expressions imply random
courses of events for which the individual cannot be held responsible. On the
contrary, someone who ended up in or got stuck in a situation appears as a
passive victim, driven by active forces outside the individual (see Fowler 1991).
The SBF seems to take a victim perspective on ‘the user’; in Sahlin’s (1994)
words, they are just “poor wretches” (“stackare” in Swedish) who have not made
an active choice to start using drugs. Sahlin (1994) puts forward the concept of
“wretch” in relation to that of “scoundrel” (“usling” in Swedish), by which she
means individuals described as unmotivated and incorrigible failures.
And how should one value an ideology that in practice leads to a forcing down
into ever deeper misery of those already excluded. (Press release, early 2003)
…those who have yet not fallen into the hell of drug use. (Press release, early
2003)
To say that someone ended up in drug dependence through a conscious decision
is nonsense. (Press release, early 2003)
The opposition against the dominant Swedish drug policy and treatment
discourse is central to the SBF’s argumentation. “The Swedish model” is
described as “moralising, judgemental and punitive”; it “harms those it has been
designed to help” and, according to researcher Peter Cohen, cited by the SBF, it
is based on moralism rather than on medical experience and scientific knowledge
(Newsletter 3). The opposition appears mainly in debate pieces and press
releases, in response to opinions expressed by other actors. This opposition to
laying the blame on the individual carries the SBF’s opposite construction – the
construction of “the innocent” user who is not blameworthy. I interpret the first
of the examples below as “one should not send out the signal that ‘it is your own
fault’ ”:
Everybody who smokes, drinks or injects knows that this is punishable. However
the signal that we send presently is that “it is your own fault if you are infected
by hepatitis or HIV”. (Article in Oberoende, No. 4/1, 2003)
We all want to see those who have become dependent get “well”, but the current
drug policy has driven people into a more and more difficult outsider position, a
position that makes it difficult for them to return to a life within the frames of
society. (ibid.)
168
Many of the texts have descriptions of ’the users’ in terms of “powerlessness”,
“isolation” and “helplessness” (see e.g. Application 2 March 2004 to the Social
Services Administration). The following quote shows that the SBF wants to shift
the responsibility for failure from ”the client” (who they imply is thought to be
responsible in the eyes of others – exactly whose eyes remains unclear) to a
particular set of actors – the treatment staff.
If someone’s medication is withdrawn because it is thought they have not
satisfactorily followed through with their treatment or for some other reason, in
many cases we know that continued treatment would be preferable. That makes
us believe that it is the doctor and the staff who did not succeed with their work
with the client, and not the other way round. (Annual report 15 October 15
October 2002)
The Swedish situation is described as chaotic, largely because of the country’s
zero-tolerance policy and goal of a drug-free society. At the same time, the SBF
seems optimistic about the future and expects to see positive changes, even
though there still remain some enemies, such as the Hassela Nordic Network, the
National Swedish Parents Anti-Narcotics Association (FMN) and the National
Association for a Drug Free Society (RNS), who continue to put the blame on
the user. The SBF is opposed to the criminalisation of personal drug use, which
it considers as a sign of moralising. The police are portrayed as “disturbing and
harassing” drug users and as consciously interfering with their personal integrity
rather than working to maintain order and enforce the law. “The user” should not
be seen or treated as a criminal, and thus as responsible/guilty.
The Swedish Users Union is tired of the war that is being waged against people
with the wrong kind of dependence. … If we receive adequate care, the right
treatment and if we are not labelled as “criminals”, amazing forces can be
released. In the future our dependence should be no more remarkable than sugar
dependence. Decriminalisation could be the first step. (Press release 27 April
2004)
Police violence and coercion, including urine samples, blood samples and other
coercive measures against drug users, have to end. (Newsletter 6)
Criticisms of treatment in the texts are also opposed to the view of users as
guilty; examples include the critique of closing down detoxification beds, of
difficulties in gaining access to substitution treatment, and of the use of
collective punishment in substitution programmes. In general, these critiques
focus on the tendency of municipalities, health care services and substitution
programmes to moralise about “the user”, which makes it harder for “the user” to
get access to the treatment s/he needs.
But what is most upsetting of all is the death rate for those “discharged” from
methadone and Subutex programmes: “Discharged” is new-Swedish for being
thrown out against one’s will. The most common reason for such involuntary
discharge is relapse into misuse. In other words, relapse into the disease and
169
dependence for which the patient has been prescribed medication is punished by
withdrawing that medication. (Press release 11 May 2004)
Among other things, the threat of compulsory treatment has often been part of
the so-called “voluntary agreements” in which we have been involved.
(Response to political query on compulsory treatment 27 June 2004)
The two quotes above also serve as examples of the attempts by the SBF to
redefine the meanings of expressions used by others, such as “discharge” and
“voluntary agreements”. Another example of this kind of redefinition is the
reaction to a debate article where the author emphasises the need for greater
“clarity” in relation to drug users. In the SBF’s view, “clarity” equals
punishment (Article in Dagens Nyheter 20 August 2003).
It seems that the SBF does not want to construct ‘the user’ as “culpable”, except
in their confirmation of the existence of this construction when they react against
a moral perspective. “Misbehaving users in treatment”, another theme of the
dominant Swedish drug policy discourse, does not show up either. In so far as
the SBF uses this meaning, it is connected to the harsh control and strict rules of
treatment providers (see the sixth quote in the section “The Innocent”). The
users that want treatment and want their drug use to be strictly controlled are
also absent from the SBF’s texts. “The innocent” is a common position of ‘the
user’ in the texts and the opposite of the subject position of the drug user in the
criminality perspective of harm reduction – “the criminal subject” (Hurme
2002). This subject is a morally corrupt and dangerous individual who should be
held responsible for her or his actions.
Discussion
In my search for descriptions of ‘the user’ in the SBF’s texts, I found four
distinguishable themes – “the consumer”, “the weak”, “the sick” and “the
innocent”. These themes happened to correspond to the subject positions of drug
users identified by Hurme (2002) in four perspectives on harm reduction – the
human rights perspective, the public health perspective, the disease perspective
and the criminal perspective. “The innocent”, however, can be regarded as the
inverted version of the subject in the criminal perspective.
The SBF’s texts clearly highlight the moralising nature of the dominant Swedish
drug policy discourse, in which criminalisation, control and marginalisation are
key features. According to the texts, this dominant discourse has also influenced
the treatment of drug users. Substitution programmes have applied very strict
inclusion criteria91 and a lot of effort has been invested in preventing “leakage”
91
These criteria have been relaxed for methadone, however, although tightened for
Subutex during 2005.
170
of methadone and Subutex into the illegal market with the help of urine tests.
The SBF draws attention to the use of collective punishments within these
programmes. Furthermore, the dominant drug policy discourse has prevented
intravenous drug users from gaining access to clean needles. Nodal positions
(see Laclau & Mouffe 1985) in the construction of the user seem to be “morally
responsible”, “incapable of making good decisions” and “criminal”.
The Swedish Users Union was founded in a situation where alternative
perspectives on drugs and their users had begun to destabilise the hegemony of
this restrictive drug policy. This might have been due to increased drug use,
policy changes in neighbouring countries and a weakening of voluntary
organisations against drugs. An alternative explanation for the space that
“suddenly” appeared for a user organisation is the trend towards increasingly
individualised treatment, with individuals expected to take greater responsibility
for their situation. In order for individual responsibility to be possible,
individuals have to be seen and treated as strong. Perhaps strong groups are also
better heard? By claiming that users are involved in decision-making or asked
about their opinion, decision-makers can legitimate a particular policy even if
users’ opinions are not in fact taken into account. In this sense the dominant
actors need user organisations, as is also discussed in this publication by
Willersrud & Olsen in relation to the emergence of Norwegian user
organisations. The question is whether the SBF can in return manage to
influence the dominant drug policy from within the space available to them, or
whether they will be “co-opted” (see e.g. the article by Tops in this publication).
The SBF could further be seen as dependent on a few individuals who are strong
enough to take on this difficult task.
The SBF’s position is that users’ interests have not been taken into account in
the current restrictive policy and therefore they are opposed to it. It is clear from
the texts quoted here that the SBF feels that the users union and its members are
part of the out-group, but it would like to be in the in-group. Below is yet another
example which points at the presence of the human rights perspective in the SBF
discourse.
Where union representatives are involved in the discussion it becomes
impossible to talk about drug users, in an objectifying manner, as “those” – “the
other”. We want to be part of society and be able to take part in what society has
to offer to all its citizens. (Application 2 March 2004 to the Social Services
Administration)
Like the alcoholism movement, whose discourse was opposed to the dominant
moralising discourse regarding alcohol, the SBF borrows its view of “the user”
from a medical discourse. This seems to be one way in which the SBF wants to
destabilise the closure or fixation of meaning in the dominant Swedish drug
policy discourse. “The user” is described by the SBF as a sick person who is in
need of medication. It wants to normalise “heroinism” or “drug dependence” by
171
comparing it to diseases that are not the subject of moralising and for which
necessary treatment/ medication is readily provided (e.g. insulin for diabetes).
Methadone and Subutex are thus constructed as medications. Curiously, though,
methadone and Subutex are also treated as “drugs” in the SBF’s insistence that
its board members should be “drug users”, and users of methadone and Subutex
are included in this category. The focus on medical treatment implies an even
greater reliance a medical discourse than the alcoholism movement’s, where
medical solutions were not part of the discourse. Interestingly enough, restrictive
drug policy was also grounded in a view of “the misuser” as a “disease carrier”
spreading an “epidemic”. It was from that perspective that measures, partly
police based, were to be focused on the users rather than the dealers.
Perhaps it is to avoid confusing their perspective with the kind of ‘medical
perspective’ described above that the SBF is keen to combine the “disease
perspective” with the view of the user as “weak” and “innocent”. SBF’s texts
include a construction of the user as passive, with other forces outside the user
placing her/him in a marginalised position – “weak”. The constructions of ‘the
user’ as “weak”, “sick” and “innocent” are not all that different – sick
individuals are often seen as weak and not to be blamed, but with the dominant
drug policy discourse connecting “the sick user” to “the morally responsible”,
there is certainly a point in separating them. The “innocent” construction further
facilitates the positioning of the SBF in relation to the dominant drug policy
discourse. The construction of the user as weak and innocent has its roots in the
leftist movement that in the 1970s regarded the problems of drug users as social
and stated it was the fault of ‘capitalist society’ that certain individuals had a
problem with drugs (see Modig 2004 for examples of the reasoning of the Rassociations92). Although “the weak” are often seen as “innocent”, one could
imagine a user that is weak now, but culpable for having put her- or himself in
this weak position. Equally, the reverse is thinkable – a “strong” person that is
not to be blamed for his/her position. I therefore distinguish between the two.
The SBF texts include many traces of a social perspective (or in the words of
Lindgren 1993, of the treatment and reform strategy). The SBF writes about the
problems as social and seems to view the individual as a victim of circumstances
in the critique of the punitive policy and build-down of treatment, as well as in
their quest for societal responsibility, in the defence of the weak and in their
wish for solidarity (many texts end with “warmth & solidarity”). The use of the
term “comrades” for SBF members can also be traced to 1970s left-wing groups.
At the same time, the SBF views are clearly distinguishable from leftist
movements such as the R-associations. In some texts the SBF seems to relate a
social view to a moralising perspective, against which it takes a stand by
preferring a medical perspective. Addressing problems with individually based
measures such as medication was not part of the solutions adopted by the leftist
92
The group of so-called R-associations was a gathering of socio-political organisations
founded during the 1960s and 1970s.
172
movement (as portrayed by the R-associations), which was rather concerned to
change society (Modig 2004). Another difference is that the SBF borrows terms
from a market discourse, including competition, private treatment and
individuality before collectivism. Since the heyday of the R-associations there
has been a general shift towards the right in politics (Boreus 1994). However,
Tham (2005) argues that the reason for Sweden’s persistent restrictive policy lies
in a “utopian left” who wants to see responsible individuals working together for
a better society, which is why no one should be given up on and why the goal is
total rehabilitation. This “utopian left” might also be what the SBF is opposing
with its more individualistic approach. On the other hand, it should be pointed
out that left- and right-wing parties in Sweden have agreed on the directions of
drug policy.
As regards the social/medical, the SBF seems to view the user as a victim and
weak at the same time. It wants to see “the user” as comparable to any other
patient who can make sound choices between treatment options as an expert in
her/his own situation (see the analysis by Asmussen 2003 of “empowerment”
strategies where clients are constructed as experts entering into partnerships with
professionals). On the one hand, the SBF seems to offer external explanations
for the problems – society has marginalised the user; on the other hand, its
solutions are mostly individually based. Individually based solutions do not
preclude societal solutions and a construction of external explanations to the
problems. However, it is not quite clear to what extent the individual is regarded
as responsible for the solution of her/his problem, although the SBF clearly
thinks that society needs to provide better treatment and a better general situation
for the user.
My interpretation then is that the SBF sees itself as a spokesperson for “users” in
treatment, or for users who want to gain access to treatment and who regard the
treatment organisation as problematic. Other meanings of ‘the user’ that do not
fall within the frames of questioning or wanting treatment have been pushed out
to the field of discursivity, in the terms of Laclau and Mouffe (1985). In an
outline for a programme by the SBF, seven out of eight issues concern the ways
in which substitution treatment should be improved and made more readily
available (Newsletter 6).93 In this regard the SBF shares many features in
common with a patient’s organisation. It mainly discusses issues concerning
treatment and needle exchange. A more pronounced user organisation might
have been thought to focus more on individuals’ rights to use drugs and their
strength and ability to make their own choices – a type of organisation that
seems to exist in Holland, but which is unlikely to gain space within the confines
of Swedish drug policy. One difference between the SBF and Dutch
organisations (and to some extent Danish organisations) is that the Swedish
union, even though it is also arguing (albeit not very emphatically) for a
93
The eighth and last point is a suggestion to decriminalise the personal use of drugs.
173
decriminalisation of personal use, does not take a stand for (or against)
legalisation. This can be understood as either a conscious or unconscious
survival strategy: if it were to adopt a stance that departs too radically from the
dominant drug policy discourse, that might well preclude it from any further
involvement in negotiating meanings and influencing drug policy and treatment.
The SBF texts reveal something about the boundaries of what can and cannot be
expressed in the Swedish drug policy debate at the beginning of the 21 st
century.94 This implies that drug users who do not want to belong to the category
of “poor creatures” still lack a “voice”; it also explains why the user is portrayed
as weak rather than strong. The SBF’s position can be understood as a balancing
act to challenge established beliefs and still to be taken seriously in a restrictive
climate of debate.
To sum up, ‘the user’, as well as the SBF, is fragmented, i.e. has multiple
positions. ‘The user’ has no single identity, but rather several meanings that are
used depending on the discourse concerned. The meaning is dependent on
contemporary constructions of ‘the user’. I interpret the SBF discourse as a
reaction against constructions of ‘the user’ as morally corrupt in the dominant
Swedish drug policy discourse, and as having the aim of destabilising its
hegemony through deconstructions, such as the ones of “voluntary agreements”
and “clarity” mentioned above. In themselves, the deconstructions aim at
changing the actions and measures taken by society vis-à-vis users and at
increasing their right to be treated in the same way as other patients. In this work
the SBF discourse reproduces a medical discourse, a closely linked
individualistic discourse (and thereby a liberal discourse focusing on human
rights) and a consumption discourse (also linked to the individualistic and liberal
discourses), as well as a leftist solidarity or human rights discourse, which
together form the SBF discourse on ‘the user’.
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Appendix 1. Material used in analysis
Press releases:
Press release 11 May 2004
Press release 6 May 2004 concerning article in Dagens Nyheter 4/5 about misuse of
Subutex.
Press release 30 April 2004 Market competition for methadone and Subutex; individual
treatment possible at last!
Press release 27 April 2004 concerning editorial in Expressen on 9 April about a woman
who was locked up, beaten and raped and thereafter refused damages because she was
under the influence of amphetamine.
Press release 22 March 2004 concerning the suggestion for new guidelines in substitution
treatment with methadone and Subutex from the National Board of Health and Welfare.
Press release 21 March 2004 concerning the suggestion that all counties should be given
the opportunity to apply for permission to treat heroin dependence with methadone and
Subutex from the National Board of Health and Welfare.
Press release 4 March 2004 in connection with the conference arranged by MOBilisering
mot narkotika in the Rosenbad Conference centre about over-prescription of medication
classified as narcotics.
Press release concerning the suggestion from drug co-ordinator Björn Fries on how the
needle exchange programme should be arranged 27 February 2004.
Press release concerning a petition against the closing down of M:48 and the delivery of it
to Birgitta Sevefjord 24 April 2003.
Notes on the discussion about whether there should be a needle exchange programme in
Stockholm
177
Articles/debate:
20 August 2003: Dagens Nyheter: Free needles save lives and suffering.
16 August 2003: Expressen: Clean needles save lives.
22 May 2003: Södermanlands Nyheter: About mistreatment in the Subutex programme in
Nyköping.
22 May 2003: Will there ever be a needle exchange programme in Stockholm?
April 2003: Oberoende no. 4/1-2002-2003 by Hjerdin, Björn: Free needles and treatment
do not exclude each other. Response to debate article in Stockholm City 20 March 2003.
Newsletter:
Newsletter 2.
Newsletter 3.
Newsletter 4.
Newsletter 6.
Website:
www.brukarforeningen.com
Responses to political queries:
Knowledge overview concerning substitution treatment from the National Board of
Health and Welfare, November 2002.
Compulsory treatment 27 June 2004.
Subutex-methadone 27 May 2004.
Needle exchange 24 May 2004.
Applications for funding:
Application 26 June 2003 to the County Council (Landstinget).
Application
2
March
(socialtjänstförvaltningen).
178
2004
to
the
Social
Services
Administration
Annual report 15 October 2002, Social Services Administration.
Application 31 May 2004 to the County Council (Landstinget).
Covering letter for Application to the Social Services Administration (socialtjänstförvaltningen) 10 November 2004.
Application to the National Board of Health and Welfare, 2005.
179
A Happy Compromise?
Public Injection Rooms in Norway
– Admission Criteria and Client Responses
Hilgunn Olsen
Sited in the centre of Oslo, Norway’s first supervised drug injection facility
opened on February 1, 2005. This article reviews early operations, admission
criteria and the response of clients to both. What was the thinking behind the
criteria put in place by the authorities? How appropriate in the opinion of drug
users are these criteria? The article addresses some of the issues related to the
facility’s establishment and operation. Noting that public injection rooms can not
solve the problems of the city centre’s drug using population completely, I round
off with an examination of the measure’s limitations in light of its initial phase.
Oslo’s public injection room is basically a place where drugs can be injected
safely and in hygienic surroundings, under the supervision of health workers and
social workers. Clients get a syringe, needle, an Alkotip disinfection swab,
sterilised water, filter, ascorbic acid and heating utensil. 95 Users bring their own
heroin dose which is shown to the staff on arrival. The facility can handle four
clients at a time, and in each cubicle there is a candle to heat the mixture. Staff
offer advice about injection techniques and the amount of heroin to inject. Staff
are on hand in the rest room outside the injecting room to monitor possible
overdosing, and to help clients get in touch with other healthcare and social work
agencies and programmes.96
Within the first few weeks of opening, 160 persons had registered as clients of
the facility, mounting to 300 by August 31, 2005, at which point capacity
problems made it impossible to accept more. Opening hours extend from 9:30
a.m. to 3:30 p.m. every day of the week. The service became an instant hit with
drug users, and soon proved too small in relation to the demand.
95
96
Alkotips are sterile swabs impregnated with isopropyl alcohol. They are used to
disinfect the skin prior to injection to reduce the risk of cross-infection. The heating
utensil is used to heat and dissolve a mixture of heroin and ascorbic acid in water,
forming an injectable solution. Known as “smoking heroin” in other countries, the type
of heroin preferred by most Norwegians is difficult to dissolve in water; the addition of
ascorbic acid speeds up the process.
In Hedrich’s (2004) classification, this type of injection room is a “specialised
consumption room”, which, unlike the “typical injecting room” and “integrated
facilities”, is not sited next door to other services (ibid.).
180
That said, the facility was and remains contested among experts, drug users and
the public. It would take all of three and a half years from the passing of the
necessary legislation by the Norwegian Storting (national assembly) to the
opening of the service. The debate and arguments for and against are explored in
detail by Skretting (2001 & 2003).
The use and management of the facility must comply with statutory laws and
regulations.97 Clients must be at least eighteen, classified as “heavy heroin
users”; only heroin may be injected on the premises; and clients are allowed to
bring no more than one user dose into the facility. The views of the user
community and user organisations were obtained as part of a 2003 government
consultation and from interviews with focus groups. I refer frequently to these
opinions in the following.
A few days into the lifetime of the facility, we conducted focus group interviews
of eighteen residents (five females and thirteen males) of Oslo’s low threshold
shelters, to ascertain views of active drug users about the injecting facility. The
interviews and consultation responses reveal a wide range of opinions: indeed,
the consultation responses of ex-users and active users show in particular how
differently the two groups view the arrangement. Opinions converge more in the
focus group interviews; these focus groups comprised active users only however.
Interviews with Oslo injection facility clients in the autumn of 2005 provide
further data.
In this article the term “user” means “drug user”. Users are divided into active
and former or ex-users. This was done to see how far the two groups
agreed/disagreed on various subjects. Injecting heroin users comprise the group
served by the injection facility. Their views on procedures and practices shed
light on the function of the facility. All assistance provided by the state is by
definition a public service, and the government is increasingly taking steps to
obtain the opinions of affected members of the public to a particular issue. For
instance, Oslo’s Alcohol and Drug Addiction Service conducts user surveys of
its front line services, where clients are asked to evaluate service delivery. There
is growing recognition among professionals and in the public in Norway of the
short-sightedness of having drug free rehabilitation as the only goal in
rehabilitation efforts, and that more needs to be done in the area of harm
reduction. According to harm reduction philosophy, the opinions and
perspectives of users are supposed to guide practice (Asmussen & Jöhncke
2004). Harm reduction as a concept nevertheless indicates a general acceptance
of the existence of drugs and drug use; of a high rate of physical, mental and
97
See Regulation no 1661 of 17 December 2004 related to the pilot scheme (Forskrift
17.12.2004 nr. 1661: Forskrift om prøveordning med lokaler for injeksjon av narkotika
– Sprøyteromsordningen) [Regulation No. 1661 of 17 December 2004 regarding pilot
scheme with supervised drug injection facilities]. Hereafter referred to as the
Regulations.
181
social problems among users; and of ways of tackling those problems (ibid.).
The biggest changes in harm reducing practices in Norway in the past twenty
five years are represented by the inauguration of the needle exchange services
and, most recently, public injection rooms.98 Harm reduction covers a number of
measures, some of which address individual harm, others harm to society (NOU
2003:4). According to the “job description” of the supervised drug injection
facility, individual harm reduction is the paramount objective.
Why Now?
Why supervised injecting rooms should appear on the agenda at the turn of the
new millennium is a difficult question to answer. Official drugs policy in
Norway has held steadfastly to a vision of a drug-free society. There is no
change on that point.
The Government is clear in its opposition to liberalisation and decriminalisation
of drugs. The Government maintains as its overarching drug policy goal a drugfree society, a goal which forms an integral part of the Government’s wider
vision. The ban on the use of drugs for non-medicinal purposes will remain in
place. (Regjeringens handlingsplan mot rusmiddelproblemer 2003–2005, 13)
Norway has been trying to solve the drug problem since the 1960s through
control, prevention and treatment, with little success, leaving responsible
authorities increasingly perplexed. What should be done? What can be done?
According to Skretting (2005), the high incidence of drug-related mortality, the
rapid increase in numbers of injecting users and the generally poor state of
health of drug users spurred the authorities to pilot supervised injection facilities.
But there was an added political reason: politicians need to show that they can
act, and drugs offer a particularly conducive area in that sense (Tham 2001). As
drug-related problems multiplied and the predicament of users worsened,
pressure mounted on politicians locally and nationally to do something.
Switzerland (1986), the Netherlands (1994), Germany (1994), Spain (2000) and
Australia (2001) were all running supervised injection facilities. 99 Also Canada
broached the issue, opening its first facility in 2003. Responsible politicians
spied a rare opportunity to demonstrate vigour and determination, in a more or
less desperate attempt to contain the growing problem. Injecting rooms offered a
relatively simple measure to organise – and would be relatively affordable too.
98
99
Harm reduction policies go back some way in Norway, with drop-in centres emerging in
the 1970s. Originally dubbed “warm rooms” (“varmestuer”), these drop-in centres have
since been known as “places to be” (“væresteder”) and latterly low-threshold cafés
(“lavteskel caféer”). Practice apart, harm reduction as a concept in Norwegian
rehabilitation work only emerged in the 1980s.
Terminology varies from country to country. Some prefer ”user room”, others
”consumption room”; Norway chose “injecting room” (“sprøyterom”).
182
Much the same reasons induced other countries to set up injecting rooms
(Hedrich 2004).
What do Injecting Rooms Aim to Achieve?
The official aims of injecting rooms are set out in the Regulations.100 Prevention
of harm to health is the general objective; under this come four others:
■ help consolidate the dignity of heavy drug users
■ facilitate contact between drug users and the health and social
authorities, and offer counselling
■ help prevent infection and the spread of disease
■ reduce overdoses (OD) and overdose mortality rates
In our interviews with active drug users we asked them what they thought of
these goals. None of our interviewees were critical per se, though some
questioned the fourth aim, to cut overdosing and OD mortality rates. Given the
small number of clients handled on a daily basis by the service, interviewees
believed the impact on OD mortality rates would be limited at best. “Any effect
would be like a drop in the ocean,” said one, to which another added, “and with
us as the drops.”
Comparing Norway’s objectives with those of other countries, we note for
instance the more general phrasing of Germany’s goals. The two top objectives
of the German scheme are
1. improvement of health for drug users living in the open or visible drug scene;
2. Reduction of the public nuisance caused by open dealing and drug use.
(Zurhold et al. 2003)
The Norwegian objectives are largely comparable with those of other countries,
though with one major exception (Hedrich 2004; Gjesdal 2004). Norway has
never seen reduction of public nuisance as the business of injecting rooms. We
return to this aspect of the Norwegian approach below, in the section on
sanitation.
Do Injecting Rooms Bolster the Dignity of Clients? The
Views of the User Organisations
As mentioned above, two consultations were held on supervised injection
facilities. The first took place in 2001 in an effort to elicit views on the
100
See note 3 above.
183
establishment of the service. It was a relatively limited consultation round, and
none of the user organisations took part. The second, more wide-ranging
consultation, was held in 2004 and concerned the Bill and Regulations. 101 This
time, various organisations invited to take part, including in the drug-related
field Recovered addicts Interest Organization (Rusmisbrukernes Interesseorganisasjon – RIO) and Tønsberg Users’ Association (BrukerForeningen i
Tønsberg – BFiT), both of which submitted responses. I include here for the sake
of relevance the submission lodged by the Norwegian Prisoners Association
(Straffedes organisasjon i Norge – SON) as prison inmates frequently use drugs
as well. BFiT and SON are organisations for active users of legal and illegal
substances. RIO is for former users only, and any substance abuse (including
alcohol) by members results in sanctions. The organisations are further described
and discussed in the article by Willersrud and Olsen in this publication.
In RIO’s submission, the organisation made their opposition to injecting rooms
abundantly plain. Their objection centred on their interpretation of the term
“dignity”, which in their view had little to do with the dignity envisaged with the
injecting room scheme (RIO 2004). Dignity became one of the most frequently
used arguments for establishing injecting rooms in Norway (Skretting 2001). In
RIO’s opinion, injecting rooms are an undignified way of treating people; they
imply in effect that users have no value. Injecting room “activists” misuse the
word “dignity” in their advocacy of injecting rooms, because the scheme would
simply underpin the lack of dignity. The organisation called instead for more
detox clinics, stressing that active users have no conception of what is good for
them (RIO 2004). RIO’s arguments are familiar enough, having figured in
debates on Norway’s policy on drugs for many years.
Coming from a different direction, Tønsberg Users’ Association (BFiT) came
out in favour of the scheme. “This is something most of our members are looking
for, and as a special interest organisation, it is in our opinion a fundamental and
necessary initiative, one of a range of excellent low-threshold services” (BFiT
2004). BFiT are strongly opposed to what they term “self-appointed experts”
defining what dignity is and what it is not, without ever having used a syringe,
adding that “dignity as far as the user is concerned means being heard and
having their needs taken seriously”. Given some background knowledge of the
two interest organisations and their differences make it relatively easy to
decipher the addresse of BFiT’s criticism, not least because their submission
refers to an incident in which Oslo city council were reported to the police.
According to the allegations, the council were aiding and abetting in the
commission of a criminal offence by running the injecting room (Aftenposten 10
December, 2002). The charge was brought by the Alcohol and Drugs Forum
101
Consultation submission.
184
(Alkohol og narkotikaforum), a body set up by RIO and several other abstinence
oriented organisations.102
SON are also in favour of the scheme. One finds in their submission also
reference to the divisions separating the various special interest organisations,
not least which of them knows best (SON 2004). SON support user organisations
that conform with the Danish Drug Users’ Union (Brugerforeningen i
København – BiK), keen advocates of injecting rooms in Denmark (Asmussen
2005). In my reading of SON’s submission, one senses an unwillingness on their
part to go along with user associations like RIO, despite calls in the submission
for better cooperation. The debate involving the various organisations is detailed
by Willersrud and Olsen elsewhere in this publication.
Admission Criteria
As the bill was being drafted,103 it was made clear that admission would have to
be regulated in some manner. Once registered as clients, however, users would
be free to avail themselves of the facility as far as capacity allowed. A need was
expressed to keep admission criteria to a minimum to preserve the low-threshold
character of the service (Ot. prp. nr. 8 2004–2005).
The admission criteria set out in the Regulations are as follows:
1) clients must be at least eighteen years old;
2) clients must be heavy heroin addicts;
3) clients may only bring one user dose of heroin into the injecting room,
all other substances and amounts are banned outright;
4) and clients must be registered.104
Two further criteria were included in the draft law, but were thrown out by
parliament.105 One of them required users to be involved in substitution treatment
(LAR rehabilitation). The Standing Committee on Justice stated the following,
however,
102
103
104
105
In addition to RIO they are: Aksjonen mot narkomani, Forbundet mot rusgift (FMR),
Street Aid, Maritastiftelsen, Evangeliesenteret, Det Hvite Bånd, Storbyteamet, Juvente,
Ungdom mot narkotika, IOGT Oslo and Akershus and Telebamsen.
It is common legal practice in Norway to refer to opinions, submissions, intentions etc.
made in connection with the preparation of legislation in Norway to interpret legislation.
There is no exact equivalent in English for the Norwegian term “forarbeider”, but
preparatory works, travaux préparatoires and legislative history are used.
Forskrift om prøveordning med lokaler for injeksjon av narkotika
(Sprøyteromsordningen). Forskrift 17.12.2004 nr. 1661 [Regulation No. 1661 of 17
December 2004 regarding pilot scheme with supervised drug injection facilities].
Odelstingsproposisjon nr. 56 (2003–2004) [Ot. prp nr. 56 (2003–2004), Ministry of
Justice].
185
It is the opinion of the majority that it is not the responsibility of injecting room
staff to ascertain whether clients are undergoing substitution treatment (LAR),
and the majority therefore sees fit to recommend the removal of this particular
criterion. (Ot. prp. nr. 56 2003–2004)
The criterion was therefore not adopted by parliament. The same considerations
were brought to bear on the proposed criterion which would ban users from
helping each other inject. Exactly how the criteria work in practice is discussed
below in the section on consultation submissions from the user organisations and
interviews with active users.
What do Users Feel About the Criteria?
Only a minority of our focus group participants said they would use the injecting
room insofar as they had a place to live, and needed above all peace, quiet and
security when they injected. A survey done in Sydney, Australia, of injecting
drug users found similar reasons for preferring to inject at home rather than in
the city’s injecting room (Wright & Tompkins 2004). Several focus group
respondents said they would have no compunction about using the injecting
room if they had nowhere to live. Some of the respondents with a place to live
felt the medical advice provided by the injecting room staff sounded useful,
partly because they injected in the groin, where the risk of bleeding is high. In an
autumn 2005 survey of users of the Oslo injecting room, we asked about living
conditions: 16 per cent had no permanent abode; 42 per cent owned their abode;
25 per cent were quartered in centres, apartment buildings or shelters; and 13 per
cent lived with their parents. One of the most frequently cited reasons given by
people with somewhere to live for using the injecting room is the safety aspect:
the number indicating this reason was as high as 78 per cent (SIRUS,
unpublished data). Talking to users of the injecting room in less formal settings,
we discovered that some of them with a place to live use the injecting room out
of consideration for others in their household, parents and/or partner for
instance.
While BFiT make no mention of the criteria in their submission, SON offer
several observations. In general they are opposed to constraints because clients
will be in a vulnerable position anyway and need whatever help the service can
offer. RIO do not review the criteria per se, but they are not keen on admission
criteria because in practice it is impossible to make sensible comparisons of
injecting drug users.
As the battle lines between the various user organisations on the injecting room
issue are relatively robust, we felt it would be interesting to explore the views of
the users themselves. Do they side with RIO or with BFiT, or with neither?
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Indeed, to what extent do these organisations reflect the concerns and interests of
the user population?
During the focus group interviews and before handing out the admission criteria,
we asked our respondents if they were aware of them. Although the interviews
took place in the immediate aftermath of facility opening and none of the
respondents had used it yet, at least one in every focus group was aware of the
issues involved.
Registration
To become a registered user of the injecting room, applicants undergo a
relatively strenuous assessment. Those who qualify receive a registration number
they need to declare every time they use the facility. Users also need to complete
a short form about substances and amounts taken in the past twenty-four hours.
The information obtained about clients will be used later to evaluate the scheme.
As it is defined in Norway as a health service, the staff are required by law to
keep records. Users in each of the focus group interviews were quick to raise the
subject of “control” before we got to mention it. Several were particularly
dismayed about the detailed information required for registration purposes. One
respondent put it like this:
I know I’m paranoid … that’s why I get stressed out when they say you have to
register and get a number. But … how in hell can we be sure who gets to see all
this [information] or gets access to it, whatever you people tell us?
One of the issues facing the pilot scheme came up in a discussion about
registration procedures. While it is important to define the facility as a health
service, with qualified staff on hand to provide care and information, the facility
is not a health service in the generally accepted sense of the word. The Health
Service Personnel Act needed to be amended before health workers could work
at the facility. The conflict between having to keep records and running a lowthreshold service was partly mitigated by exempting facility staff from elements
of the registration duty. At the same time, some level of registration is necessary
to identify those who meet the criteria and obtain evaluation data.
At Least Eighteen Years Old
Clients must have passed their eighteenth birthday – the age of majority in
Norway – to register. As the draft bill states, one of the main objectives of the
pilot scheme is to prevent people turning to drugs. It is assumed here that not
many under-eighteens sort under the category “heavy drug user”, and that those
who do should be dealt with by the health service through other means than the
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injecting room (Ot. prp. nr. 56 2003–2004). Not all of our interviewees agreed
with the Ministry’s arguments on this point, however.
I think the injecting room should be an intervention by which intravenous use by
youngsters under eighteen is recorded, because there’s a lot of injecting users
under eighteen. It’s important to explore the habits of this group, because it’s
easier to get them to change. So just cutting the under-eighteens as an age-group
out altogether is, in my opinion, plain stupid.
The person who said this believes there are more injecting drug users under the
age of eighteen than the government, and it is vital precisely for that reason to
encourage them to use the injecting room. Most agree with the government’s
policy of letting other parts of the health service scoop up these youngsters, but
are not convinced that it actually happens. The speaker quoted below disagrees
with putting age limits on welfare, and feels it’s up to the police to prevent drug
use among the under-eighteens.
Either you have to build police numbers to stop these kids getting hold of drugs,
or open the welfare and health services up for them. That’s what I think. It’s
obvious really.
There is then a certain amount of dissatisfaction among the user groups we
interviewed to setting the age limit at eighteen. The Norwegian age limit is
identical to that of other jurisdictions, in Europe and further afield (Hedrich
2004).
One User Dose of Heroin
The point of banning substances from the injecting room apart from the single
heroin dose users are allowed to bring is to prevent buying and selling on the
premises. It was also a roundabout way of allowing heroin to be used in a
restricted area of the health service without opening the sluices on heroin use
and possession in general. An amendment was necessary to decriminalise
possession of the single heroin dose intended for injection on the premises. This
means that while all drug use remains illegal in Norway, a person can not be
prosecuted for possession and use of a single user dose within the confines of the
injecting room. If the amount of heroin had not been limited to one user dose, it
would have created anarchy for the police. How could they be expected to
enforce the ban on possession, use and sale of drugs if possession of unlimited
quantities inside the facility was simultaneously exempt from prosecution? In
practice it would have meant the decriminalisation of heroin, something
Norwegian politicians are firmly against.
Another problem associated with the decriminalising of the single user dose is
the failure of the provisions to define what a single dose means in practice,
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leaving it up to the police to decide whether a given amount represents an
offence, who to charge and who to let go. Limiting the amount to a single dose is
impractical however you look at it, according to SON, because it varies from
person to person, and it is cheaper to buy several days’ worth of the drug at the
same time. This variation in what a user dose is in practice was touched on in a
conversation between two of our respondents:
A: A single dose, that’s a packet or a gram or half a gram, or what is it?
B: How do they know if you’ve brought one or ten [doses] with you?
A: A dose, that’s….
B: It depends.
Respondents also wondered how the injecting room staff were supposed to tell
how much a client brought into the facility. This was a question the drafters of
the law pondered as well. Although on occasion staff might find it difficult to
determine the substance or the quantity, it should be possible to do so in most
cases. How they were expected to do this, however, was not specified (Ot. prp.
nr. 56 2003–2004). And while user doses may vary, a limit has to be drawn
somewhere, as several of the consulted bodies pointed out, including the
National Police Directorate. Several interviewees said much the same.
A: It can be anything from a quarter [0.25 grams] to a half gram.
B: That’s right, from a zero-point-one [0.1 grams] to a quarter, half a gram or a
gram.
A: There aren’t that many who use a whole gram for one dose.
B: No, true.
A: But half a gram, that’s common enough.
B: Half a gram is normal, but not a whole gram.
In light of the signal effect, RIO criticised this haziness about what a dose added
up to in practice. They opposed exempting doses used in the injecting room from
prosecution. It is hardly surprising to see opponents of injecting rooms criticising
this aspect of the scheme, because it is virtually impossible to enforce the
regulations to the letter. It would be out of the question to instruct health
personnel and social workers to search people’s pockets and bags for drugs over
the quota. That is a job for the police, and only the police are authorised to do it.
Injectable Heroin Only
It was the overdose risk that lay behind the ban on other substances; the risk
increases when heroin is mixed with other drugs. The authorities also wanted to
convey a message. “Allowing the consumption of other drugs in the injecting
room could be interpreted as tacit support for the practice.” Heroin is injected
more frequently than other drugs, the authorities added. The habit of combining
drugs goes against the grain of the project, and indeed operative
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recommendations (Ot. prp. nr. 56 2003–2004). A large number of the consulted
bodies and organisations were averse to a ban on all other substances in the
injecting room, but the scheme’s basic premise effectively ruled out any such
leniency.
If the point were only to secure the dignity of the drug users, one could perhaps
have considered allowing drugs other than heroin. But the pilot scheme is there
to serve other purposes, such as reducing overdose rates and harm caused by the
injection process. (Ibid., 4)
Heroin is the main substance used in supervised injection facilities in other
jurisdictions, though cocaine is also permitted (Hedrich 2004). While cocaine is
not widely used in Norway, it is increasingly common to inject Rohypnol
together with heroin. SON advocate relaxing the rules to allow drugs other than
heroin to be injected in the injecting room. Many are dependent on other
substances and tend to inject them together with heroin. It was this aspect of the
regulations the respondents were most aware of prior to the interviews. They
wanted freedom to mix heroin and Rohypnol; without it, many said they would
never use the injecting room, because they depend on both drugs. Heroin on its
own doesn’t give them the right “fix”. Others, however, were not convinced of
the magnitude of the problem.
That stuff about only heroin having to be injected in the room, it’s OK it’s in the
law as long as nobody checks what you put on your spoon and heat up, so there’s
a tiny loophole to add other stuff as well. And that’s fine.
Staff would hardly be scrutinizing what people put into their heating utensils and
syringes, this informant believed. But in practice, staff are often aware of
attempts to mix substances, especially if Rohypnol is involved. The drug’s
strong colour makes it relatively easy to spot. The next time a person suspected
of mixing drugs turns up at the injecting room, s/he is told where they stand and
given a warning. Nevertheless, a significant proportion probably do get away
with mixing drugs, something our interviewees expected would happen.
… you could have a screen. You’d be on your own, and could make your
compound without nurse seeing what you’re doing. And I’m pretty sure that’s
what’s going to happen down there, I think.
As the quotes show, having a chance to inject a mixture of drugs is clearly
important to many users, and a ban in itself is insufficient to turn them into users
of heroin only.
Heavy Drug Users
To gain entry, a person needs to be categorised as a “heavy drug user”. The
clause was included to prevent “people using the injecting room to try heroin for
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the first time in a supervised setting”. Not defining what “heavy drug user”
meant was a deliberate omission; politicians wanted to leave it to the discretion
of the injecting room staff (Ot. prp. nr. 8 2004–2005, 14). Injecting rooms in
other jurisdictions apply more or less the same criterion (Hedrich 2004). But
what is a “heavy drug user”? Some would say anybody who uses heroin; others
anybody who injects. One of our interviewees offered this definition:
Heavy drug user, someone who’s hooked on heroin whether it’s been for six
months or ten years. Doesn’t matter.
Others envisaged more strenuous criteria, and offered reflections to that effect.
And what do you think they look like then? Totally washed out or something?
A discussion between two users illustrates the disinclination to categorise
oneself as a “heavy drug user”; they believe outward appearance determines how
others are likely to categorise them.
A: It depends on how you feel as well. Ergo, I’m…
B: Ergo you’re stigmatised again. OK, so I’m a really heavy user myself
[ironically].
A: The day you visit the injecting room, dress as shabbily as possible.
B : I only hope to God I don’t look like a heavy drug user. I expect we all try not
to look like one.
As the discussion shows, restricting admission to “heavy” drug users appears to
be working exactly as envisaged by the authorities. It is assumed by the drafters
of the bill that the term “heavy drug user” would in itself serve to limit potential
clients. Some of the members of the Standing Committee on Justice wanted to go
further than the majority and let clients rather than staff decide whether they
fitted the term. “The door to the injecting room should be open to those who
define themselves as heavy drug users, a designation hard enough to apply to
oneself” (Ot. prp. nr. 8 2004–2005, 13). As the user quoted below makes clear,
some are completely averse to the label. Indeed, going along with the definition
would be humiliating.
You feel like you have to bow down, you know … filthy clothes and … just dirty
all over sort of. Put your shoes on your hands instead. Crawl through the
doorway.
In assessing a potential client’s admissibility, the drafters of the act wanted staff
to take account of his/her self-definition. But as the above quotes show, our
respondents do not feel run down enough to fit the description. (This despite
living at one of Oslo’s low-threshold shelters, normally a place one would expect
to find the city’s heaviest drug users.) There is an echo here of the introduction
of methadone treatment in Norway in 1994. The intention of the methadone pilot
scheme, according to Frantzsen (2001), was to help the fifty eldest and most
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derelict drug users. Frantzsen described how several addicts began compiling
files to describe how wretched they were. It spurred the adolescent psychiatry
section at Ullevål Hospital to wonder whether the project had not made
applicants more wretched. At the same time, the selection criteria adopted by the
methadone project were so strict, even the most run down found it difficult to
pass muster. For instance, they needed to be “drug free” in the week before
starting their course of methadone treatment. But at the same time, their ability
to function had to be very low indeed; otherwise they wouldn’t be “wretched”
enough. In Frantzsen’s considered opinion therefore, the project criteria
effectively kept the people for whom the project was designed from participating
in it (Frantzsen 2001). We see something similar with the injecting room project.
By requiring clients to be heavy drug users, politicians and authorities are clearly
indicating a desire to reach the most down and out and debilitated users. But at
the same time, this is where dependence on a mixture of drugs is the most
prevalent. In other words, the most needy users are unable to satisfy the
admission criteria. Injecting room clients need to be “down and out – but only to
a degree”.
Our respondents felt the registration criteria raised several problems. Did they fit
the bill, or were they too functional perhaps? A likely consequence of this could
be that the people in the target group simply refrain from registering because in
their own judgement tells them their habit isn’t “heavy” enough. Nevertheless,
the present criterion is wider than the methadone project’s. And in practice, it is
extremely difficult for staff to send people away on grounds of not being
“heavy” drug users if clients themselves claim to fit the label.
Control Versus Necessity
The users we interviewed experienced registration criteria as a form of control.
Their critical submissions contrast strongly nonetheless with the popularity of
the service. Could it be that the criteria prompt a range of opinions among clients
or could there be other explanations for the discrepancy? An exchange between
two of our respondents suggests people feel it is better to pay the price of
submitting to control than having to inject in filthy doorways, with security
guards and police ready to pounce on every corner.
A: If I hadn’t lived here now, I’d have to say I’d have used it [the injecting room]
myself. If the alternative was a filthy multi-storey car park or something. Not to
mention security guards waiting to throw themselves at you.
B: It’s the way things are today, we have to find somewhere to do it. It’s a pain,
but manageable.
B: True, but when I’m sitting in an injecting room, even with all those controls
and stuff, at least I know there’ll be peace and quiet, nobody ready to jump on
me.
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Their fear of what they term “control” has to do with the city’s approach to
control. Following a period of relative lenient policing of possession and use, a
stricter line came into force again from mid-2004. Before then, injecting drug
users tended to congregate in the square in front of Oslo’s main station, the drug
trading centre since the end of the 1990s. With the introduction of low tolerance
policing, however, this author has only seen a single instance during the monthly
surveys of the drug scene in Oslo centre of an injection administered on the
street. The higher stop and search frequency is the likeliest explanation. Users
we interviewed were not at all sure how the police would react to the injecting
room and its clients, as the quote below illustrates.
Theoretically speaking, the police can park themselves outside [the injecting
room], and then just pounce on people in order. When people come and go, I’m
pretty certain they’re going to keep the place under surveillance and make notes.
That’s my personal opinion. Because you might be bringing … I was going to
say five grams and a hundred Rohypnol with you, you know. It’s one reason at
least I’m staying clear of that injecting room.
The quote reveals no confidence in the ability of the police to handle the
injecting room issue with tact. But the control implicit in the registration criteria
is not the only thing feared by the users. They are also afraid of being stopped
and searched on their way to and from the facility. The opinions of the
interviewees contrasted with the popularity of the injecting room suggest that
people are not willing to let concerns about the registration criteria and control
stop them from using the service.
Issues Connected With Establishing the Injecting Room
The intensity and range of the debate accompanying the opening of the injecting
room give some indication of the problems involved when services of this nature
are given the go ahead and run by the state. Drugs are illegal in Norway, and will
remain illegal; however, some of the country’s drug users have permission to
inject heroin under the supervision and guidance of state-employed health
workers. How is this possible? Clearly, setting up and operating the injecting
room bring a number of difficult issues to the fore.
What is the Position of the Police in Relation to the
Injecting Room Scheme?
When the guidelines were made known, criticism was not long in coming.
Impunity for possession of heroin in the injecting room posed a serious
challenge, said the police. How were they supposed to enforce this regulation?
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While possession of a user dose of heroin is an offence outside the injecting
room, it would be disloyal of the police to position themselves outside such
places with the intention of stopping and searching persons on their way in. On
the other hand, “being on one’s way to the injecting room” cannot be taken as a
reason to sidestep the law. (Director of Public Prosecutions, 22 December 2004)
This formulation is not very clear on how police officers are supposed to act on
the ground. Indeed, as the Director of Public Prosecutions himself admits, it is
impossible to apply hard and fast rules wherever local councils decide to open an
injecting room; local police chiefs, he adds, must instruct the police in their own
district (ibid.).
In the event, however, the problem never materialised. During the first months of
operation, the police left clients alone. This in turn raised another issue. Is it fair
to let registered clients of the injecting room walk around in possession of a user
dose with impunity, while other drug users remain liable to prosecution for doing
the same thing?
Sanitation?
To sanitise something means to spruce it up by removing unwanted elements.
Oslo city council’s waste management division collects rubbish, for instance,
and makes the city tidier, neater. In the same way, sanitation as a metaphor106 has
been used of policies intended to remove undesired elements from the public
eye. It used to be a widely accepted strategy in Norway, as the (now historical)
Vagrancy Act testifies.107 Under the Act, public drunkenness could result in a
fine or incarceration with hard labour. When the Act was amended in 1970,
public drunkenness ceased to be an offence and hard labour a way of dealing
with homeless alcoholics was abandoned.
It was widely hoped that the injecting room would be used by the drug scene in
the Skippergate area,108 not only for the good of the drug users themselves, but
for local businesses and the public. While Norwegian politicians shy away from
saying so outright, it is obvious that injecting rooms improve public order by
reducing injecting in public places. In other jurisdictions, cleaning up the streets
has been one of the main aims (see e.g. Hedrich 2004; Reinås & Cron 1998).
And it is true that the injecting room remove the act of injecting from the public
gaze. We do not know where injecting room clients would have injected in the
106
107
108
The Norwegian term used here is renovasjon. It has the dual meaning of renovation in
the usual sense (renovation of buildings, art works etc.) and waste management / waste
disposal etc.
Lov av 31. mai 1900 om Løsgjængeri, Betleri og Drukkenskab (Act of May 31, 1900,
relating to vagrancy, begging and drunkenness).
After the square beside the main station was cleared, the drug scene shifted to
Skippergata, a few hundred metres further south.
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absence of the injection facility, but many would doubtless continue to do so in
public. In an autumn 2005 survey of injecting room clients, 69 per cent said their
last injection would have taken place outdoors somewhere if the injecting room
didn’t exist (SIRUS, unpublished data). Several members of our target group
broached the subject independently. Some felt treated like dirt by the authorities,
and that waste management was what drugs policy was all about in reality.
I feel really strongly … that the authorities are trying to hide us away as far as
possible…. But they need to realize once and for all, they’ll never get rid of us.
Drugs will always be there. We’re always going to be part of the street scene.
They can’t get rid of us. However hard they try.
When the Vagrancy Act was repealed in 1970, the motion’s spokesperson asked
his parliamentary colleagues where it was written that derelicts were a sanitation
problem, adding that
As long as our society creates vagrants, we must accept the fact head on. It is
better to have a true picture of the city than a clean picture. (Mathiesen 1975)
Although it is more than thirty years since this was said, it has lost none of its
significance. One important difference between the 1970s and now is that back
then, people dared call vagrants a sanitation problem openly. Norwegian
politicians today take great pains to hide how far policy making relies on this
type of thinking. Government anti-drug action plans usually include phrases to
the effect that how a city looks should never serve as a measure’s only
justification.109 The leader of the Conservative Party (Høyre) stated in 1973, as
reported by one of Norway’s major papers, “if we want to ensure progress, we
move quickly to eliminate what we might term spanners in the works” (ibid.). In
2005, the police officers’ association suggested that sanitation had been a major
factor in the 2004 efforts to relocate the drug scene in the city centre. “This is
outrageous!” the leader of the Department of Welfare and Social Affairs in
Oslo’s Conservative City Council rejoined, “improving the look of the city has
never been a motive, we have only ever had the drug users at heart”
(Aftenposten, 3 March, 2005). On the other hand, several drug users interviewed
by us agree about the need to take account of the feelings of the public about the
drug scene. One interviewee put it like this:
It [the injecting room] is a brilliant way of shielding [injections] a bit … I’m
thinking about tourism and the public, you know. Even though I do it myself, it’s
horrible to watch. Avoid sitting in doorways and mainlining. I’ve done that too,
but I don’t think I would today. So I hope that’s a thing of the past now we’ve
got an injecting room. I really do.
109
Two instances of which are Regjeringens handlingsplan mot rusmiddelproblemer
2003–2005 [Government action plan on problems related to drug use 2003–2005] and
Tiltaksplan for alternativer til rusmiljøene i Oslo sentrum [Alternatives to the Drug
Scene in the Centre of Oslo – A Plan of Action 2003–2005].
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Skretting (2003) observes concerning the steps taken in 2003–2005 to disband
the city centre drug scene 110 that an obvious aim was not only to secure better
health and social services for drug users, but also to clean up the streets. She is
confident the same can be said of the decision to set up the injecting room.
Unconditional Help or Encouraging a Harmful Habit?
One could see the injecting room as encouraging people to inject drugs. Users
could interpret it along the lines of “we’ve given you lot up, just feel free to
carry on injecting harmful substances”. We know that injecting does more
physical damage than taking drugs by other routes, like smoking for instance.
We also know that injecting is the preferred technique in Norway; only a
minority smoke heroin or use other techniques. Is it then justifiable to make it
easier for people to perform as hazardous a technique as injecting potentially
lethal substances in reality is? Coming from this angle, ideas about securing
dignity and respect don’t have much chance, if by dignity we mean that drug
users are people with a potential to grow and develop in many ways were it not
for their drug habit. Others would say that dignity is being accepted as one is,
non-judgementally. That it is chiefly through encounters of this nature, for
instance between users of the injecting room and staff, that the seed to an
enhanced sense of self and improvement of the individual’s life situation is
shown. Perhaps the authorities should have set up a smoking room instead, or at
least one in addition to the injecting room, with a view to motivating injectors to
smoke heroin, and improve people’s chances in that way?
How much the authorities could and should do to facilitate harmful habits among
the citizenry is anyway a question requiring constant reappraisal in connection
with the design of what we term “harm-reducing measures”. Can we envisage a
situation where it was clear that “things had gone too far”? Has establishing the
injecting room where staff are not allowed to inject the drug shifted the
goalposts? Staff are employed to supervise and guide clients, not to inject the
substance into his/her body. At a general level, it is harder to say where the line
should be drawn. Should we allow injecting rooms and not allow prescriptions
for illegal drugs? Should we allow the prescription of substances in organised
drug programmes, such as the heroin prescription project in the Netherlands, or
even go as far as letting high street chemists dispense substances free of charge?
One would be justified in thinking that the discussion of where to draw the line
will become increasingly urgent in the years ahead.
110
The steps commented by Skretting are set out in Tiltaksplan for alternativer til
rusmiljøene i Oslo sentrum 2003–2005 [Alternatives to the Drug Scene in the Centre of
Oslo – A Plan of Action 2003–2005].
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Double Message
One pertinent question raised in the discussion on injecting rooms concerned the
initiative’s legitimacy in light of Norway’s wider intentions to achieve a “drug
free society”. It is not easy to deal with this type of duality, as several
interviewees pointed out.
It’s illegal to use heroin in the city, so why are we allowed to shoot heroin there?
Not unexpectedly, the proposal to organise an injecting room sparked a fierce
debate which not unexpectedly turned into a debate about the basic design of
Norway’s drugs policy. Papendorf (2004) explains why the discussion focused
so quickly on the premises of drugs policy in Norway.
The corollary of advocating for injecting rooms is to admit that the vision of a
drugs free society was misconceived. The struggle for the injecting room which
dominated the public discourse during the summer of 2003, has in this sense a
highly important symbolic value. If the struggle is lost, advocates of the drug
free society will have lost the battle. (Papendorf 2004, 42)
That the injecting room was established could be taken as indicating that
powerful special interests of politicians and the public per se also regard harm
reduction as an important drugs policy premise. The debate surrounding the
injecting room made clear the strength of the views lined up on either side, and
the establishment of the injecting room is proof that we in Norway are trying to
give something to both sides at the same time. We want a drug-free society and
we want harm-reducing measures for those in need of them. Many believe this to
be a difficult, if not impossible, combination. The admission criteria adopted by
parliament were doubtless necessary given Norway’s general position on drugs,
and micro-management was probably necessary to make the proposal politically
acceptable. Commenting on the government’s drafting of the bill, the head of the
national Data Inspectorate said, “One hears the term grudging used of the
consultation paper compiled by the Government, something I find easy to
understand insofar as its authors do not appear to believe it is a good idea”
(www.nrk.no 2005). Oslo city council go so far as to say in their response to the
consultation paper that the pilot scheme is hardly practicable at all, given the
many compromises required of the various vested interests (Oslo Kommune
2004). This recalls the climate surrounding other controversial harm-reduction
projects, such as the German heroin project for instance. Papendorf (2004)
describes how that programme’s stringent admission criteria turned it virtually
into a “high-threshold project”. Heroin may only be administered intravenously –
a requirement of the Norwegian injecting room also. But if we ask how these
relatively inflexible rules came to be adopted, Papendorf says as follows:
we are shown in the direction of the political concessions required to get the
proposal through. At the end of the day, it is about achieving a political
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compromise without which the project would never have left the starting blocks.
(Papendorf 2004, 54)
Frantzsen was led to the same conclusion in her study of the methadone project.
It was the result of wheeling and dealing, something else entirely than a welljudged and well-considered project, she says (Frantzsen 2001).
Conclusion
One of the key issues with the establishment of the injecting room concerns the
likely benefits of the service to society. Will it help cut overdose rates? Will it
ease contact between the health and social welfare authorities and the drug
users? Are individual clients likely to feel more valued? Will it result in less
physical harm among the target group? It is too early to assess achievements and
consequences. There may be unanticipated consequences, beneficial and/or
harmful. The authorities and most active drug users share a generally optimistic
view of the service’s ability to work as intended. A large majority of the active
drug users we interviewed were clearly in favour of the injecting room because it
would make life less complicated in the longer term, as envisaged by the
authorities. Among former drug users, the injecting room meets with less
unmitigated enthusiasm; in their opinion, its objectives will probably not be
achieved to the extent anticipated. The organisations of active users are actually
more likely to reflect the views of the target group in the injecting room debate.
Several issues about the injecting room informed the public debate. One of them
focused on the registration procedures and criteria required to ensure optimal
operations. A certain amount of control of clients and the way in which the
facility is used is necessary to ensure safety and allow for evaluations later. But
at the same time, it is supposed to be a low-threshold service.
As a further issue, the injecting room may strike some as rather incompatible
with Norway’s averred drugs policy, jeopardising the coherence of the
government’s message. How is it possible for a country which holds to a vision
of a drugs-free society to open an injecting room? It may be possible to uphold
the vision while acknowledging the conditions under which drug users live, and
attempt to do something for them. But in extension, one could question the point
of maintaining the vision at all.
The third issue revolves around what I called above the sanitation aspect. How
far is the injecting room an expression of a desire to clear undesirables off the
streets? Norwegian politicians are unwilling to admit its relevance to prevent
public nuisance and other measures directed at the drug scene. There is no doubt
that the public are disturbed by the sight of people injecting drugs, and that
consideration of the public good informs policy making. One can only hope this
198
discussion will proceed in a climate of openness where all voices are given a
hearing.
The question forming the fourth issue is whether using the injecting room is
dangerous in itself. Injecting potentially lethal substances is hazardous not only
because of the risk of overdosing but because it harms the body. Can the
authorities morally justify to make it easier for people to pursue harmful
activities of this nature? And if there is a limit to society’s toleration of harmreducing interventions, where does the cut-off point go?
The final issue at the present stage is to do with the position of the police on the
injecting room pilot scheme and impunity for possession of a single user dose
when intended for injection on the premises. Is it fair to let clients of the
injecting room carry a user dose with impunity on the street, while others with
similar amounts risk prosecution? Isn’t there supposed to be equality before the
law?
In the heated debate leading up to the opening of the centre, “injecting room”
increasingly sounded like a magical incantation, as if saying the magic words
would make all problems besetting official drugs policy go away. It is not a
magic spell, of course, and there are clear limits to what an injecting room can
do, either for individuals or the community as a whole. An injecting room does
not affect the marginalisation of drug users. The life of the clients will remain
more or less unchanged whether some of the injections are performed under
professional guidance and in hygienic surroundings. Personnel have an
opportunity to engage with the clients, referring them to other health and social
welfare agencies and programmes, liaising between various parts of the “system”
better placed and equipped to help the individuals in question. However, the
admission criteria may in fact be excluding some members of the target group.
The criteria probably dissuade many from giving the service a try, believing they
have little hope of passing the admission test anyway. The injecting room’s
impact on public order will be limited. Insofar as public order or sanitation is
one of the premises of the injecting room, as long as it remains a noncompulsory service, its “sanitation” impact can only be limited. Whether drug
users avail themselves of the service or not is up to them, and there is no
evidence the city centre drug scene is declining in the wake of the service’s
establishment. There will always be a large number of injecting drug users who,
for various reasons, are not interested in becoming clients of an injecting room.
As the service is organised today, not only is the number of registered clients
limited, opening hours are restricted as well. Many are disqualified because they
are under age, use the “wrong” type of drug, or were simply too late to register.
When the final batch of thirty clients was registered, applicants were asked if
they lived in Oslo and whether they intended to use the centre on a regular basis.
199
Again, one wonders whether it is fair to proceed with a service which only
benefits a small minority of drug users. Who needs the injecting room most of
all, and are they the ones registered as clients of the service? This is an urgent
question because we are dealing here with an intervention which, at the end of
the day, is intended to save lives. It is a difficult question to answer, and was
only cursorily addressed before the injecting room opened.
Translation: Chris Saunders
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201
On Whose Terms?
User Participation in Danish Methadone Maintenance
Treatment
Vibeke Asmussen
Introduction
User participation, in the context of social work, is a concept that holds a
multiplicity of meanings. In general, it is understood as providing users of social
services with greater control and influence over their own lives. User
participation can be analysed as an ideology and/or as specific techniques used
in social work (Asmussen 2003; Asmussen & Jöhncke 2004; Bjerge 2005;
Schwartz 2001). The present article focuses on how techniques of user
participation are applied in the practice of social work. It sets out to discuss two
ways of giving users influence over their own lives: 1) through the
implementation of legally prescribed techniques to encourage user participation
in social services, and 2) through specific performances of the relationship
between user and social worker. The article is based on experiences of user
participation at four Danish methadone maintenance clinics.
User participation in social services became statutory in Denmark in 1998. The
new Act on Social Service prescribed two kinds of techniques for user
participation: user councils (a user participating forum) and social activity plans
(a user participating tool for organising and coordinating treatment). Since these
methods are statutory, I understand them as formal techniques of user
participation. However, the experience from the four clinics was that both of
these techniques were difficult to implement. Despite these difficulties both staff
members and users themselves felt that there was a high degree of user
participation at the clinics. This feeling, I will argue, was embedded in specific
performances of the relationship between social workers and users.
The concept of “user” implies in itself a rethinking of the relationship between
user and social worker. Adams (1996), for example, describes how a “user” is
understood as a resourceful person, an expert in his or her own life, who actively
participates in changing his or her situation, in opposition to the “client”, who
has connotations of a weak, dependent and powerless person who passively
receives social services. The social worker provides solutions to the “client’s”
specific needs. The “user” and the social worker, on the other hand, engage in a
partnership and the social worker help to facilitate changes in the user’s life. The
202
empowerment perspective places the “user” and his or her own perception of the
problems in the centre and so returns to him or her the power to change the
situation. In this way empowerment is fundamentally about democratising the
relationship between the user and the social worker or institution and giving the
user greater influence over his or her own life. At the four methadone clinics, the
relationship between user and social worker was based upon a sense of trust
instead of control, it was more pragmatic, and made use of support contact
person schemes (støttekontakt-person ordning)111 in order to help drug users with
the problems and life circumstances that they had defined themselves. I describe
these specific performances of the relationship between user and social worker
as informal techniques of user participation. Formal techniques of user
participation focus more on different ways of organising social work, whereas
informal techniques focus more on how the relationship between user and social
worker is performed. The two techniques should not be seen as mutually
exclusive, but rather as interdependent.
In the following I describe and discuss two important issues related to user
participation: First, why is it so difficult to implement formal techniques of user
participation in methadone treatment; and second, how do the above-mentioned
informal techniques actually empower users in their own treatment? The
adoption of an empirical approach to user participation and to experiences of
both formal and informal techniques of user empowerment has two main aims:
1) to draw attention to some of the practical dilemmas involved in formal and
legally prescribed techniques of user participation and 2) to show how other
techniques can give the user possibly even greater influence over their own
treatment than legally prescribed techniques.
The article is based on a three-year qualitative study of the four methadone
clinics. The descriptions and analyses are based on 42 qualitative interviews with
counsellors and 37 qualitative interviews with users. In addition, participant
observations were conducted at all four clinics. One of the key aspects of the
study was to examine the interplay between the different actors involved. Here I
focus exclusively on the interaction between counsellors and users in regard to
user participation.
The Four Methadone Clinics
In 1999 the Danish parliament decided to set up a pilot on methadone treatment
with extended psychosocial support. This pilot was intended as an alternative to
a heroin trial. Instead of changing the substitution drug used – from methadone
111
In some respects the support contact person scheme can be compared to case
management or a trajectory manager. The Danish version of this initiative is described
below.
203
to heroin – the aim was to find out whether extended psychosocial support could
improve the effect of treatment with methadone. Four new methadone clinics
were set up for a term from 2002 to 2004/2005 using various types of extended
psychosocial support (Asmussen & Kolind 2005). The four clinics all focused on
user participation as a way of motivating users to get involved in their own
treatment and thus of achieving better results from extended psychosocial
treatment. The four clinics were located in Korsør (A), Silkeborg (B), Århus (C)
and Copenhagen (D) (see Table 1).
Three of the four clinics (A, B, C) enrolled the most seriously affected drug
users and, like heroin trials elsewhere in Europe, focused on offering beneficial
treatment to drug users described as “treatment resistant”. Among the specific
criteria set for these users, they were to be aged over 30, have more than ten
years' history of heroin abuse, and have tried various forms of treatment. They
were all users who were known to the treatment system, but they had either
failed to adhere to treatment programmes aimed at reducing the physical damage
resulting from active abuse, or they had not benefited from the treatment they
had received. In contrast, the fourth clinic (D) did not enrol a defined target
group. Here the users were selected randomly from standard treatment
programmes in Copenhagen and the user group was much more diverse
(Asmussen et al. 2003). The discussion below demonstrates the relevance of this
difference between the users enrolled with regard to user participation.
Extended psychosocial support in the four projects has relied on a very low
counsellor/user ratio (see Table 1).
Table 1. User/counsellor ratio in the four methadone projects.
Project
A
B
C
D
Counsellors
4
2
6
8
Users
28
11
30
60
Ratio
1:7
1:6
1:5
1:8
At all four clinics, extended psychosocial support consisted effectively of an
intensification of methods and initiatives already used in methadone treatment,
such as counselling, therapeutic interviews, and the provision of training and
employment opportunities. At the same time, new methods and initiatives were
introduced, such as drop-in centres. Counsellors also provided users with help as
part of the support contact person scheme, assisting them when they needed to
visit the doctor, dentist or welfare office. Other elements included social activity
plans, user councils, and various kinds of activities (e.g. sports, handicraft or
picnics). Counselling was offered whenever needed by the client, or at least
every other week. In standard treatment it is not unusual that counselling is
provided only once every three months (Pedersen & Asmussen 2002). New
initiatives, for their part, are either non-existent or very rare in standard
204
treatment (ibid.). Initiatives such as user councils, social activity plans, and the
support contact person scheme are therefore all new forms of psychosocial
support in methadone treatment in Denmark (Asmussen & Kolind 2005).
Legal Aspects of User Participation: User Councils and
Social Activity Plans
User participation became statutory in Danish social services with the
introduction of the Act on Social Service in 1998 (Asmussen 2003). The Act
prescribes various techniques of user participation techniques. The technique
used for involving users at an organisational level is that of user councils, at an
individual level that technique is social activity plans. Below I outline what these
two types of participation imply.112
User Councils: Organisational Participation
A user council is a democratic forum where users and staff and/or management
within a treatment institution can work together to discuss and make decisions
on various factors concerning treatment. A user council can be set up in different
ways. Users can be elected or selected to sit alongside staff representatives and
managers. User councils can also be open to all users who wish to participate
along with staff members or managers.113
In the brochure User participation for vulnerable groups, Thomsen (2000)
identifies the following areas in which user councils can be involved: a) the
formulation and approval of a philosophy for the treatment institution, b)
specifying targets, methods and subsidiary goals for the initiative, c) physical
layout, d) house rules, e) opportunities to give opinions on recruitment and
dismissal of staff members, f) the creation of concrete services or treatment
offers, and g) being informed about and allowed to express opinions about all
112
113
A third type of user participation prescribed in the Act on Social Service could be called
participation at a political level. This means that users have a visible voice in political
fora and in public debate more generally. Political participation requires the involvement
of user organisations where they have the opportunity to contribute to the relevant
political debates. The guidelines for this political involvement are laid down in §114 and
§115 of the Act on Social Service, where the municipalities or counties are called upon
to set up advisory cooperative bodies to which voluntary organisations can be invited to
discuss the organisation of an initiative. In this publication Jørgen Anker discusses this
aspect in his article about the Danish Drug Users Union (DDUU).
The Act on Social Service does not explicitly specify user councils as the forum that
social services must establish to allow user participation. It does, however, prescribe that
the municipality shall establish councils for users and relatives in connection with
nursing homes, and this comes immediately after §112 which states that municipalities
and counties have a duty to ensure that users can exert an influence on social services.
205
issues of significance to the user group (Thomsen 2000, 38). The reason I have
chosen to mention this brochure is that it is aimed at vulnerable groups and it
was produced as a type of guidance or inspiration for the user participation
prescribed by the Act on Social Service. The possibilities that according to
Thomsen are open to user groups, as we will see later, are far removed from the
functions allocated to user councils at the four clinics.
Social Activity Plans: Individual Participation
The Act on Social Service requires that social activity plans are drawn up jointly
by the municipality’s social security office and methadone treatment centre in
close consultation with the user. The plans must be based on the user’s own
terms.114 The Act further states that the social activity plan must be produced in
writing and specify the ultimate goal for the user. It must detail the initiative that
is necessary in order to achieve this goal, how long it is expected to take, and
include other circumstances such as accommodation, employment, personal help,
treatment or necessary aids. In other words, the social activity plan sets out what
is expected to happen to the user in the planning period. It is aimed at changing
or improving the user’s situation. Social activity plans should be revised after a
certain period, for example six months. This should include an assessment of
what has been achieved during this period and a listing of the priorities for the
following six months.115
Formal Techniques of User Participation in Practice:
Opportunities and Limitations
The following proceeds to describe how user councils functioned at the four
clinics, the difficulties they encountered, and suggests reasons as to why it is so
difficult to implement user participation in the form of user councils in
methadone treatment. This is followed by a corresponding discussion for social
activity plans.
114
115
Social activity plans are described in §111 of the Act on Social Service. It should be
stressed that methadone treatment can also involve plans other than §111 social activity
plans, such as treatment plans. The discussion here is confined to legally prescribed
social activity plans.
Mahs (2002) emphasises that it is unclear who is ultimately responsible for the
implementation of social activity plans and how often they should be followed up. In
this respect there is room for interpretation. However, social activity plans have been
devised as a tool for coordinating the initiative between various systems and in such a
way that the individual user or citizen can be involved in the process. Social activity
plans hence also have an important coordinating function, which I shall not deal with
here. On this topic, see Asmussen & Kolind (2005, 58–75).
206
User Councils
The preferred form of user council at all four clinics are meetings that are open
to all users, with the participation of one or more staff representatives. The
following case illustrates what was put forward for debate as well as the general
procedure at such a meeting.
The user meeting is held just before noon. Lunch is served today so many of the
users are present. There is some confusion among staff members before the
meeting gets under way, and a counsellor goes round to check among the users
whether they are coming. Several users say they do not want to attend. One of
them, however, is very interested; he says he goes to every user meeting because
it gives him a chance to exert influence. The meeting begins, and the counsellor
asks whether they should start by drawing up a weekly plan. There are four users
at the meeting with the counsellor. One of them complains about the poor
attendance: “it’s just not good enough that 20 people are sitting in the café and
cannot be bothered to come.” Another user suggests that those who do not join
in should not be allowed to have a meal. The counsellor ignores this, and asks
again whether they should draw up a weekly plan. He explains that the centre
will be closed on Friday because of the public holiday, and that they will
therefore serve the traditional warm wheat rolls on Thursday. He also explains
that on Thursday the centre will be open until 14:00 instead of 12:00, because on
Wednesday it is closing early at 10:00. No explanation is given to the users
about these changes in opening hours. A user enters the room and sits down to
join the meeting. The counsellor continues, saying that because of the changes to
opening hours, Wednesday’s and Thursday’s activities will have to swap places
so that the meal and swimming will be on Thursday. Two users interrupt and say
they do not want to go swimming on the Thursday, because their girlfriends are
coming on Wednesday. They would rather cancel than reschedule. The
counsellor accepts this. He suggests that they have a day out on the Thursday
and make a visit to the Scandinavian Animal Park, for example. One of the users
asks about departure and return times. There is some discussion as to how long
the drive takes. Then the counsellor says: “So, we all agree then, do we?
Scandinavian Animal Park on Thursday.” Nobody really answers. The
counsellor carries on: “I suggest we all go on an outing together in the summer,
like last year. Maybe it could be a canoe trip?” One user complains and says he
does not want to go, because he is sure he will only end up falling in the water.
Another user says he would like to go. He grew up with canoes. They fail to
agree on whether or not they should go on a summer outing. Instead, the
counsellor makes a couple of announcements before asking: “Is there anything
else we should talk about?” The users say no, but two of them start complaining
again about the absence of the other users. The user who was last to enter agrees,
even though he has taken no active part in the discussion. The counsellor does
not join in, but as the discussion winds down, he says: “The meeting is closed.”
The user meeting lasted approximately 15 minutes.
Only four out of a total of 30 users at the clinic took part in this meeting. It was
run by a counsellor and focused on forthcoming activities. The meeting lasted no
more than 15 minutes. This is by no means an untypical example, but in general
attendance at user meetings was very low at all four clinics. The agendas covered
nothing beyond what is described in the case above: users were informed about
changes to the weekly schedule, activities and trips were organised, the menu for
207
the next communal meal was planned, or rules of behaviour for users at the
clinic were debated.
The experiences from user meetings at the clinics are indeed far removed from
Thomsen’s (2000) proposal mentioned above. The meetings gave users only very
limited influence over treatment practices at the clinics. Nonetheless all four
clinics tried throughout the pilot to make the user councils work, with arguments
like: “Personally, I think it makes sense to give the signal that users have a
responsibility to bear. The fact that I haven’t seen a user council work in practice
is another matter” (counsellor). The counsellors were also aware that the nature
of user participation at methadone clinics may differ from the “textbook” formal
techniques of user participation:
We – how can I put it? – middle-class people have a notion of what user
participation should be. We want influence, and we have to accept responsibility
and so on. But for our users, exercising influence might consist in something as
simple as the choice of one type of coffee over another. And perhaps they don’t
have the personal resources to manage any more influence than that.
Another counsellor said:
I bet you a million that if you explained to users what user participation means,
and if you asked them whether they were participating in their own treatment,
they would say yes. I know that from our contacts. We talk about everything. We
talk about my girlfriend or his girlfriend being an idiot, that my children are ill,
or whatever else you can talk about. We also talk about life as a drug user, and
what will happen when they get old. So I think they feel they are participating.
The fact they are not participating according to the book is quite another matter.
It is clear from these excerpts that the counsellors do not expect user meetings to
be about much more than what kind of coffee is available at the clinic. However
it also emerges clearly that user participation is something that grows up out of
the contact between user and counsellor. More on this later.
The users themselves were generally satisfied with the influence they wielded
through user meetings. When asked about how the user meetings work, one user
said:
U: If somebody thinks that something is not right, we agree on a date and a time
and we have a meeting. People can then put forward their views and opinions
and we go on to sort these things out.
I: What kind of thing might that be?
U: It could be anything from the coffee being too strong to the coffee being too
weak. I think it’s really just a matter of making us feel noticed. But the
counsellors are prepared to listen if we have a view on anything.
I: Have you used this opportunity?
208
U: No, I haven’t, because in fact I haven’t been dissatisfied with anything – quite
the opposite.
I: So the user council is mainly for situations where someone is dissatisfied with
something?
U: Yeps, that’s about it.
I: Do you feel you have enough influence?
U: Yes. More than enough, I think. It’s bloody great in that regard, I have to say.
This user is satisfied with the amount of influence he has, but it is also clear that
user participation in the form of the user council is not important to him. But
why do both users and staff members have such low ambitions with respect to
user meetings?
From the users’ point of view, this has to do with their life situation and the
mutual relationships within the user group. The life situation of drug users is
obviously deeply complex, but one recurring characteristic is the constant
vacillation between stable and unstable periods. The unstable periods are
characterised, among other things, by increased supplementary use. The
increased focus on drugs makes it hard to look at anything beyond the here and
now. This aspect of the users’ life situation inflict upon the user council. In this
kind of life situation, it is difficult to meet regularly, to keep to agreed times, to
agree to carry out tasks and so on. This is the point made by one of the
counsellors quoted above when she says that users do not necessarily have the
personal resources to manage influence. Many drug users also lack the
experience of attending meetings run by a chair, which have a set order of
speaking, minutes etc. The method of exerting influence espoused by user
councils requires experience and skills that most drug users – and particularly
the most seriously affected drug users – do not have and cannot fathom. One
counsellor said: “Take a completely ordinary matter, such as writing minutes.
Many users are not very good at writing and therefore it’s always a struggle just
to have the minutes taken.” Another, albeit less conspicuous aspect which
complicates decision-making at user councils is the web of internal relationships
within the group. Grytnes (2004) has described how many users at drop-in
centres are reluctant to make decisions on behalf of other users (such as on house
rules), especially if this has consequences for other users. They are worried that
their commitment to the centre can affect their relationships with co-users
outside the centre. This aspect was also highlighted by individual users in our
interviews, although only occasionally.
However, the difficulties of getting user councils to function “according to the
book” also relate to the clinic as an institution and to its frameworks for creating
user participation. Just as in many other institutions, the clinics were constrained
by organisational and financial considerations. The staff were already there and
209
employed when the users arrived. The budget was set and fixed. The opening
hours were as long as staffing levels permitted. The premises were already in use
when the users were enrolled, and laid out so that they were suitable for the
treatment concept implicit in the project. The five weekdays were all scheduled
with various types of initiatives and activities, etc. The frameworks within which
the clinics had to run and in which the users were to be involved were thus
already established. The amount of influence that the users could exert was
therefore strictly limited.
The difficulties of implementing user participation, in the form of user councils,
at an organisational level thus have to do with the user group and its
characteristics, and on the other hand with the fact that the institutional
frameworks for involving users were already largely established. The latter
applies not only to methadone treatment, but social services in general (see also
Jöhncke 1999–2000).
Social Activity Plans
A social activity plan typically includes a description of the user’s current
situation, background, everyday life and personal resources. In addition, it sets
out the goals for treatment and specifies who is responsible for the achievement
of these goals. A social activity plan is drawn up in cooperation with the user
and is signed by the municipality, the treatment provider and the user. 116 A social
activity plan might look like this117:
116
117
Only two (A and D) of the four clinics worked systematically with social activity plans
and the experiences reported here are from these clinics.
For reasons of anonymity I have invented a fictitious social activity plan.
210
Table 2. Example of a social activity plan:
Background
information:
User’s current
situation:
(housing,
children, health,
financial
situation,
cohabitation,
etc.)
User’s
background:
(upbringing,
education, work
experience,
abuse, treatment,
criminality)
User’s everyday
life:
(interests,
networks, daily
life)
User’s own
resources:
Name of the user, counsellor, social worker, and doctor.
User’s wishes
and goals:
Lise wants a new place to live. A two-room apartment with a shower and toilet. She
wants dentures, to have her eyesight checked and perhaps new glasses, and elasticated
stockings to help the circulation in her legs.
Expectations
for
cooperation:
(user,
municipality,
project A)
Responsibility
for the
treatment
initiative:
Lise expects that she can achieve her wishes and goals through her own efforts. Project A
and the municipality expect that their cooperation with Lise will be successful, as the
counsellor is in daily contact with Lise.
Lise lives in poor conditions: a privately rented apartment with a toilet in the basement
and a shower in the yard. Because of lack of maintenance and the poor conditions, Lise’s
heating and water bills are very high. Lise has no children and is single. She receives a
pension. Lise has six teeth left. She has problems with her eyesight. And she has
circulation problems in her legs as a result of her injecting.
Lise has been receiving outpatient methadone treatment since 2000. She is prescribed
130 ml methadone preparation. She has a daily supplementary use of hash and
amphetamines. Lise has been in residential treatment on one occasion. She has been
prosecuted for possession of amphetamine, but otherwise she has not been in prison for
the last two years.
Lise’s main interest is painting. She is in contact with her mother, sister and brother-inlaw. She attends the project daily and takes advantage of what it has to offer. Her social
circle consists mainly of drug users.
Lise is creative and good at painting. She is normally good-humoured and contributes to
a positive atmosphere. Lise is good at keeping appointments and in general has a realistic
and rational attitude to life. She can often see for herself when she is partly responsible
for things going wrong in her life. Lise also has a survival ability and a pride which
benefits her in the milieu of which she is part.
Project A will work closely with Lise to find her a new place to live.
Project A will make an appointment for her to see a dentist and an optician.
Project A will obtain an application form so that Lise can apply for elasticated stockings.
A social activity plan is always based on an assessment of the user. The goals set
for enrolment in a methadone treatment programme or other social service
institution are determined on the basis of each user’s current situation and
personal resources. The social activity plan can be seen as a contract between the
user, the municipality and the treatment provider regarding what form the
initiative is to take for the individual user. In short, the social activity plan is a
tool for the provision of “individual” and “differentiated" treatment.
However, the actual compilation of social activity plans at the clinics has proved
rather difficult. At one clinic there were difficulties with the following up of the
211
social activity plan, contradicting the idea that these plans should be a guarantee
of progress in treatment and user involvement in the process. At the clinic that
had a more differentiated user group, it proved difficult to draw up social activity
plans for users in the most difficult circumstances.
But what did the users think of the social activity plans? The excerpt below is
from an interview with a user who managed the type of user participation for
which the work with social activity plans was intended. His expressed goal was
to be drug-free, and his social activity plan was primarily geared to this aim.
When asked about the drawing up of his social activity plan, he said:
U: I think it’s great, because you have to think about what you really want from
your life once you start with a social activity plan. You don’t go round thinking
about that every day if you are a drug user. It’s more about living from one day
to the next, staying healthy and getting drugs.
I: Does it matter that you are personally involved in deciding on the content of a
social activity plan?
U: Yes. Yes. Of course. Otherwise it’s the counsellor that should be in the social
activity plan!
However, the user quoted here was one of only a small minority. By far the most
users were not sure whether they had a social activity plan in the first place,
could not remember what was in it, or regarded the social activity plan as useless
or irrelevant. As an example of the latter, one user said:
I don’t like that word: social activity plan. It’s about setting a goal before a date
and then you have to reach that goal. I find it hard to focus if I have something
hanging over my head: for example if I have said to my contact person that in
one month’s time I will have cut down on the methadone. What if I don’t make
it?
Overall then, users are not very keen on the idea of social activity plans and do
not see them as a significant part of their treatment.
There are several explanations for why social activity plans are hard to
implement and why users do not consider them particularly important to their
treatment. These explanations can be found both in the user group and in the
frameworks in which treatment takes place. If social activity plans are seen as a
technique for involving users, then, just as in the case of user councils, they
collide with users’ life situation, since their lives are much more focused on the
here and now than on the future. The forward-looking, written and systematic
approach to reflection involved in this kind of treatment is in stark contrast to the
life situation of many users. Theirs is a life of navigating through chaos, focusing
on immediate problems, and relying on verbal experience and exchange (Table
3).
212
Table 3. Social activity plans versus drug users’ life situation.
•
•
•
•
The world of social activity plans
Structured
Forward-looking
Written
Systematic reflection
•
•
•
The life situation of drug users
Navigating through chaos
Acute problems
Verbal communication
Not only the user group, but also the framework of the clinics conflicted with the
requirements of social activity plans. One clinic devoted much time and energy
to creating networks of cooperation with the municipality during the pilot period;
the other clinic already had formally established channels of cooperation.
Nonetheless it was still hard to implement social activity plans as a way of
involving users.
A final explanation for the difficulties of implementing social activity plans is
that counsellors working in substance abuse treatment consider written
documentation – such as social activity plans – peripheral to the overall
psychosocial initiative. An example is provided by the following quotation:
Not everything that counts can be measured, and not everything that can be
measured counts. As far as I am aware there have been no studies to see whether
documentation is worthwhile in the first place. It is a matter of belief. I’m not
saying that there shouldn’t be any documentation, just that sometimes it’s done
for its own sake, just like making a budget. It doesn’t give you any more money,
but you know where it’s all going. The important thing about the documentation
phase is the reflection that it enforces. But this could be done just as easily with
counselling. I think it is the space for conversation that actually creates
development. It is not necessarily when I am sitting here at the computer and
having to write something. It’s just like when you send a postcard from
Mallorca: having a nice time, the food is cheap, the sun is shining – I have
documented it that I have been to Mallorca. That is pretty much the purpose of a
postcard. It doesn’t give rise to very much reflection. And it does not necessarily
say very much, at least for others who have to read it, about the content of the
project.
This counsellor has difficulty seeing the purpose of written procedures or the
written agreements implicit in social activity plans. He sees documentation as a
reduction and something that only superficially describes the user’s situation.
He also takes the view that counselling is a better way of listening to the user,
i.e. using verbal communication, as discussed above.
The difficulties of implementing social activity plans can thus be rooted in the
characteristics of the user group and in the frameworks within which the projects
are run, including the negative attitude of some counsellors to written
documentation.118
118
Other experiences of social activity plans (for example in the field of psychiatry)
indicate that effective social activity plans integrated into treatment require a targeted,
213
User or Drug User?
The concept of the resourceful user who is an expert in his or her own life and
who is an active participant in changing his or her situation, which underpins the
empowerment approach and the idea of user participation, is in stark contrast to
the picture of drug users enrolled at the four clinics. Against this background the
difficulties of implementing user participation in the form of user meetings and
social activity plans are hardly surprising. The simplicity with which user
participation can be discussed and described in the form of user councils and
social activity plans is counteracted by the difficulties of carrying out these
techniques of user participation in practice. For this reason the projects also
focused on other areas in an attempt to give users greater influence over their
own treatment.
Informal Techniques of User Participation
Three aspects of treatment were particularly important in giving both users and
counsellors a sense that the users exercised real influence over their own
treatment. The first was establishing a relationship of trust instead of control
between users and counsellors. The second was the adoption of a pragmatic
attitude towards users at the clinics. The third was the use of the support contact
person scheme.
Trust Versus Control
Working with relationships is fundamental in social work. As discussed above,
empowerment theories offer new perspectives on the relationship between user
and counsellor. Analyses of client creation also open up a critical view on this
relationship (e.g. Järvinen & Mik-Meyer 2003).
In its analyses of the relationship between counsellor and client/user, the
literature on methadone treatment focuses on the culture of treatment. Even
though this culture is not the most widely described aspect of methadone
treatment, there are studies that in various ways highlight the creation of
different relationships between counsellor and user in different treatment
cultures (e.g. Bourgois 2000; Lilly et al. 2000; Rosenbaum 1985). In a classic
article from 1985, Marsha Rosenbaum identifies three different treatment
models: the medical, reformist and libertarian model. In simple terms, these
models create users as ill patients, individuals with behavioural problems or as
conscious effort on the part of the the organisation, including training and an upgrading
of staff qualifications (Olesen 2002).
214
consumers, respectively. The different treatment models thus ascribe different
roles to the user. In other words, the various treatment models have different
interpretations of the relationship between counsellor and user, as the counsellor
necessarily has to act differently depending on whether they are faced with an ill
patient, a person with behavioural problems or a consumer. One of Rosenbaum’s
points is that the way in which control of the users is maintained depends on
which of the treatment models is used at a given methadone clinic. And control
is a recurrent theme in methadone treatment. Rosenbaum’s article inspires a
closer look at how the relationship between counsellor and user is established in
practice.
At all four clinics trust is perceived as absolutely basic to conducting any
treatment at all. Counsellors from all four clinics said in unison that they spent a
lot of time in the first 12 to 18 months creating a sense of trust among users.
Trust is in fact a totally decisive parameter in the relationship with another
person. That is ordinary human nature. It plays a significant role in establishing
contact, but then becomes implicit. It is something we now have in regard to
users, so we now need to move on with something else.
German sociologist Niklas Luhmann (1999) has argued that demonstrating trust
towards others is a fundamental part of the human condition. Trust is essential
for us to be able to act in the world, because we are always positioned in relation
to others, whose actions will affect us regardless of whether or not we want them
to. Trusting others is thus a way of dealing with the uncertainty of the future, i.e.
dealing with the fact that the actions of others have significance for our selves.
One of Luhmann’s points is that trusting another person is based on experience,
that the relationships we have with others are actually what they seem to be. It
could be said that trust is a generalised experience, and that this experience can
be extended to other similar cases to the extent that it is confirmed, i.e. that the
same experience is constructed. It is therefore reasonable to ask what trust really
means, and what it consists of. At the clinics it is about how people deal with
supplementary use and what expectations are placed on users, as the following
two quotations illustrate:
We have openness about everything, whether methadone or supplementary use,
and we give the user time. Therefore trust has been created. I think this is very
different to the experience I have had otherwise. It makes it somewhat easier
further down the road to help them with what it is really all about. It is better
than that they guard their speech for what they might otherwise reveal
People have always been confrontational towards drug users. You mustn’t bash
them on the head if they don’t keep agreements. They cannot do that. They lose
their families, for example, because they are on heroin. They think about drugs
all the time. And they have already been bashed on the head so many times
because of their failures and because they don’t keep agreements. So you have to
think differently. If this doesn’t work, what do we have to do differently?
215
The point made by the counsellors in these quotations is that trust is created,
among other things, by being open to the user’s world and the associated use of
drugs, by taking time and being patient, by being available, and by not imposing
sanctions on the user. Openness is practised in the projects by providing the
opportunity to talk about supplementary use without any reaction in terms of
treatment. This is accepted as part of the users’ world, like their housing
situation, finances and family relations, which can be dealt with in their
treatment. The use of illegal substances by users receiving methadone treatment
has traditionally resulted in sanctions, such as reduced doses or even progressive
cessation of treatment. Accepting supplementary use during the course of
methadone treatment is a strategy for creating trust between user and counsellor.
This is important since previous research has shown that substance abuse
treatment is often characterised by a high level of mistrust, with limited room for
empathy, and that treatment is often impersonal and involves a strong element of
control (Høgsbro et al. 2003; Jöhncke 1997; Hunt & Rosenbaum 1998). It is
perhaps hardly surprising then that the users describe the attitude of trust and
commitment shown by the counsellors towards them as extremely important:
They can bloody well see when something’s wrong. But it’s just great. They
worry about us. And that’s a pretty rare feeling. We’re just junkies, after all – the
scum of the earth.
My contact person came out to see me at hospital. He coddled me, and he was
just so great. It was the first time in my life someone has brought me flowers to
hospital. For me it’s the small things that mean a lot. When I was in hospital for
26 days, my girlfriend never once brought me flowers. She just came and asked
whether I could stow away some of the medicine I was getting. That’s what
addicts are like! I could easily have done the same myself. When I dried out, I
suddenly realised how the counsellor was really interested in helping me –
helping little me! As a drug addict I have never seen such a huge effort to help a
single person.
In these quotations, the users describe how they felt about being treated with
respect, noticing that their contact persons cared about them, that someone was
interested in them. They underline how valuable it is that the counsellors take
them seriously, understand their situation and listen to their problems openly,
and do not, as one user expressed it, “wag their fingers at us”. This applies above
all to being able to talk openly about supplementary use and any problems with
controlling that use. Many users have previous experiences of being sanctioned
if they talked about supplementary use (or if it was discovered), and so they had
previously tried to hide or deny such abuse. It can thus be said that the strategy
of the counsellors in being open about supplementary use and not imposing
sanctions for it is an effective way both of bringing the users into treatment and
also giving them influence over their treatment.
216
Being Pragmatic
The second area emphasised by the four clinics in giving users influence over
their treatment is being “pragmatic”. As far as the counsellors are concerned,
this, in general, means creating “resource-oriented” and “individual” treatment.
But how is this done in practice? When asked what is involved in daily
treatment, one counsellor said: “That’s completely unpredictable.” This
counsellor does not work with a planned schedule, but instead starts out from the
issues raised by the users here and now. It could be said that the pragmatic
approach is to take the user’s life situation seriously and to start from there.
Another aspect of being pragmatic is to consider the work process within the
personnel group, so it benefits the user, as the next two quotations show:
We are not particularly strict and categorical. We don’t insist that you absolutely
have to be referred to your own contact person. If it’s easier for a client of mine
to talk to one of my colleagues, that’s fine.
With one of my clients there were repeated misunderstandings, or at least that’s
what he felt. We misunderstood each other. He didn’t feel that we were reaching
each other, and fundamentally he was right. He came up with a very objective
presentation of what he wasn’t satisfied with, and what he thought was not going
particularly well. He felt that my colleague had a much better understanding of
what he came up with. But in the counsellor group we initially had a bit of the
attitude that “you can’t tell us down here what to do, we decide that ourselves”.
And so he was once again very objective and put forward some arguments as to
why he didn’t feel very good about being with me. And so he went over to my
colleague.
Being pragmatic in the relationship between user and counsellor can thus also
influence how work within the project is allocated. Being pragmatic is also
apparent in how the counsellors approach a user’s wishes, that is, in actually
taking the users’ wishes seriously.
I have a user who does a lot of heroin and I talk to him about how we could help
to reduce that. “You don’t need to help me with that. It’s just as it should be”.
Their agenda is not that they want to be treated. They never said that. They have
said that they want a better and a more orderly life and would like to be in
control of various things. That’s where I start from.
Another counsellor is pragmatic about the user’s alcohol abuse, since this has
resulted in him becoming estranged from his own children and in such serious ill
health that he is actually at risk of dying:
This user asked me quite straight out whether it would be healthier for him to
start taking heroin again instead of alcohol. I said yes, if you have no other
choice, I think you should go back to heroin. Because it’s really terrible for him,
he is destroying his liver and damaging his brain.
217
In these two quotations, the counsellors take the questions asked by users very
seriously. In the first quotation, from the user’s point of view, the problem is not
the heroin use, and it is not with that he is asking for help. The counsellor
therefore lets it be. In the second quotation, the counsellor acknowledges that the
user does not have the choice of quitting his abuse. The choice is to find the type
of abuse that has the least damaging health effects. The pragmatic element in the
relationship between the user and the counsellor thus consists of constantly
taking the user’s world into consideration and adjusting the treatment
accordingly.
Support Contact Person Scheme
The idea behind the support contact person scheme is to actively deal with the
“chaos” and “acute problems” experienced by drug users. The support contact
person scheme is a technique applied by the counsellors to help users in their
contacts with the authorities (doctors, hospitals, the municipality, the judicial
system, etc.) and to help them gain control of their own life (finances,
accommodation, contact with family members, etc.). In this way the counsellor is
active in helping the user with various aspects of his or her life. Following users
around the various social systems in order to help and support them is not
common practice in Danish methadone treatment. The motive behind this
technique is to make a “real” difference in the users’ everyday life, to help them
with things that for various reasons are difficult for the users themselves to
implement. It is well documented that drug users often have difficulties and
conflicts with municipal case officers and indeed with doctors, dentists and
hospitals, and that these conflicts can be hard to resolve (e.g. Bømler 1996).
Conflicts arise because case officers tend to see drug users as threatening and as
falling outside the norm. Drug users, however, feel that they are not listened to
or taken seriously. The counsellors point to the importance of accompanying a
user on a visit to a municipal case officer to avoid these unnecessary conflicts:
We have a huge advantage, we meet people every day. When a user has
threatened to kill their case officer, I can intervene. I have learned that for such a
psychologically weak group as users are, it is necessary that there is someone
there who can act as a buffer.
Users themselves also feel that the presence of a contact person helps to alleviate
conflicts. When asked what it was like to have his counsellor with him at a
meeting at the municipality, one user said:
It works very well. I don’t think I would have ever got there without him. He got
me to pull myself together. I had been up to talk to the municipal case officer
once, and that turned into a row. It has ended in a row many times on the phone,
so I needed him with me. If I go on my own, they don’t really listen. My contact
person can remember what I have on my mind. I can’t. I have unbelievable
problems with my memory when I am sitting there under stress.
218
The user describes how he found it difficult to go to the meeting on his own and
that encounters with the public system are considerably less conflict-ridden and
more constructive when the counsellor is present. This is both because the
counsellor can help the user to remember the agenda, and also because the user
feels he is treated better by the authorities when he is accompanied by the
counsellor.
One of the motives for the support contact person scheme is thus the frequently
poor situation of users, their chaotic lives and their occasional lack of
communication skills. Another is that the public systems and their procedures
are often highly bureaucratic and impenetrable, not just for users, but also for
counsellors, as the next case shows:
A user was motivated to undergo detoxification. The counsellor contacted
Hospital A, but was told that the medical ward was overloaded. At Hospital B,
he was referred back to Hospital A. The counsellor explained that Hospital A
was overloaded. The nurse at Hospital B said she would look into the matter and
call back. When she did, she said that she had talked to Hospital A, and been
told that if the counsellor asked the doctor at the treatment centre to ring
Hospital A, they would admit the user for detoxification. That was done, and the
counsellor and the user had to report to the emergency ward. Here they waited
about an hour for a doctor. Several times during this period, the user wanted to
leave, because he felt he was not being treated properly. The counsellor
persuaded him to stay. When they finally met the doctor, the user was heavily
intoxicated. The doctor would not admit him, though, before he had visible
withdrawal symptoms. The contact person and the user left the hospital, both
disappointed that the user had not been admitted for detoxification (case edited
from Videreførelse af Substitutionsprojektets elementer 2004).
The contact person’s role often puts him between a rock and a hard place. He has
to represent the user towards the system and deal with the user’s problems and
frustrations with that system. At the same time, he also has to deal with the
frustration that representatives of the system have with the particular user or with
drug users in general. As one counsellor put it:
Sometimes it’s easier to deal with the user than with the system. I sometimes feel
like banging my fist on the table or shouting over the phone when dealing with
the system. But of course this will not help the user. I have to get things to work.
But it is difficult sometimes. It takes a lot of energy, for example, to meet case
officers and lawyers who are angry with a user.
Another area addressed through the support contact person scheme is “clearing
up the chaos”, in other words helping with practical everyday matters. This can
be in the form of help with moving, paying bills, money matters, shopping,
washing clothes, etc. This initiative consists of many small actions that in
themselves may seem minor, but in the user’s world they all add up to a very
significant total. One user said:
U: I am more in control of myself and I am more in control of my apartment. I
have become good at keeping it clean and tidy.
219
I: When you say that you also have more control of yourself, what are you
thinking of?
U: Being clean and putting on clean clothes. Before, I just came down to get
methadone. It was just a matter of getting in, getting your dose and then out
again. If you don’t have to spend time with people, you can be a bit more of a
pig and don’t shower that often. But here, where we all spend every day
together, it’s a bit different. You start to think about what you look like. I also
mean dealing with the electricity, TV and phone bills and those kinds of things.
The counsellors helped me with all that. And they have helped me get out of a
huge debt to the state and a huge debt to a private firm.
The support contact person has helped this user gain greater control over his life.
As described above, project staff have 1) helped users deal with what they
consider acute problems; 2) made sure that users are treated fairly and properly
in other public systems; and 3) ensured that the communication between the user
and the public systems is constructive.
The clinics have given users greater influence over their own treatment by taking
them seriously and by working on the basis of the wishes and goals that the users
themselves feel are most important. In that sense the support contact person
scheme can be seen as a technique of user participation.
Concluding Remarks
In Denmark it is statutory for users of various forms of social services to be
involved in their own care and treatment, for example via user councils and
social activity plans. However the experiences of user participation at the four
clinics show that these techniques for involving users are not particularly
effective. The reasons for this lie in the users’ life situations and in the
frameworks within which the institutions work with user participation. Most
users at the four clinics were not forward-looking, organised, or oriented towards
written procedures, as required by social activity plans. They were not used to
the culture of meetings, nor did they consider it important to have or to
participate in a body such as a user council. In contrast, they were involved in
their own treatment through other, more informal techniques of user
participation characterised by a relationship of trust between user and staff.
These informal techniques took departure from the users’ life circumstances:
they accepted supplementary use, based the treatment on the users’ own wishes
and needs, and through the support contact person scheme helped users with
their everday life and their contacts with public systems. User perceptions of
participating in their own treatment at these four clinics were based upon the
approach adopted by the clinic to treatment, rather than on the legally prescribed
techniques for user participation.
220
It is, of course, relevant to ask whether it is worth spending time and energy in
setting up user councils and drawing up social activity plans in methadone
treatment. Several reasons suggest that it is. First and foremost, user councils are
prescribed by law and are a form of local democracy that should be supported
and developed. Besides being a technique of user participation, social activity
plans also have a very important coordinating function. However it is important
to emphasise that according to the experiences gained from the four clinics here,
the formal techniques are not sufficient to give drug users influence over their
own treatment. Drug users’ life circumstances differ in important respects from
the motivation behind user councils and social activity plans. If the users in
methadone treatment are to gain real influence over their own treatment, then
their life circumstances have to be taken seriously as the point of departure in
treatment. Therefore informal techniques of user participation based on the
relationship between user and counsellor must be given greater prominence in
methadone treatment than is currently the case.
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Authors & Editors
Jørgen Anker
Department of Society and Globalisation
Building 25.3, Roskilde University
P.O. Box 260
DK-4000 Roskilde, Denmark
E-mail: [email protected]
Vibeke Asmussen
Centre for Alcohol and Drug Research
University of Aarhus
Nobelparken, bygn. 1453, Jens Chr. Skous Vej 3
DK-8000 Aarhus C, Denmark
E-mail: [email protected]
Astrid Brandsberg Willersrud
City of Oslo, Alcohol and Drug Addiction Service
MAR Oslo / Villa Mar øst
Kjølberggata 9
NO-0654 Oslo, Norway
E-mail: [email protected]
Björn Johnson
Swedish National Institute for Working Life
SE-205 06 Malmö, Sweden
E-mail: [email protected]
Petra Kouvonen
Nordic Council for Alcohol and Drug Research (NAD)
Annankatu 29 A 23,
FI-00100 Helsinki, Finland
E-mail: [email protected]
Leili Laanemets
Malmö University
School of Health and Society
SE-205 06 Malmö, Sweden
E-mail: [email protected]
Hilgunn Olsen
Norwegian Institute for Alcohol and Drug Research (SIRUS)
P.O. Box 565 Sentrum
NO-0105 Oslo, Norway
E-mail: [email protected]
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Jessica Palm
Centre for Social Research on Alcohol and Drugs (SoRAD)
Stockholm University, Sveaplan
SE-106 91 Stockholm, Sweden
E-mail: [email protected]
Tuukka Tammi
Finnish Foundation for Alcohol Studies
P.O. Box 220
FI-00531 Helsinki, Finland
E-mail: [email protected]
Dolf Tops
School of Social Work
Lunds University
P.O. Box 23
SE-221 00 Lund, Sweden
E-mail: [email protected]
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