Self-organized prevention of drug-related harm: impacts of and strategies to address continued lack of harm reduction service provision in a small Swedish city

Background: There are several well-evidenced strategies for the reduction of drug-related harms, including needle and syringe exchange programs (NSP) and inclusive policies for housing of people who use drugs (PWUD) (i.e. Housing First). Despite this, the development of harm reduction has been limited in many areas of Sweden. This study aims to understand the implications that this has for PWUD’s risks and risk management in areas of low access

Methods: Eleven qualitative, semi-structured interviews were undertaken with PWUD in a small urban centre with no NSP or Housing First policy.

Results: Participant characteristics: ten male, one female, aged 31 to 55 years (average 43 years), 8/11 injecting daily or near-daily, primary drug of choice was amphetamines, followed by heroin and other opioids, and benzodiazepines. Participants reported many solutions to absence of NSP, including: travel to a distant NSP (200+ km roundtrip), creation of secondary distribution networks, stealing, borrowing, reusing, ordering online, and smuggling needles and syringes. They were at risk of having their equipment confiscated by police. Participants were mostly (7/11) homeless or unstably housed due to exclusion from housing services. Some reported substance use to cope, furthering exclusion. Strategies to address homelessness included: frequently finding new temporary housing solutions, sheltering in public places, with friends, and in cars. Lack of housing led to risk behaviours such as public injection. Participants felt the lack of services reflected stigmatized notions of drug use, and, for example, avoided accessing healthcare services for fear of discrimination.

Conclusion: The absence of harm reduction programming contributes to a cycle of exclusion and has shifted the burden of addressing risks to the individuals in the study, who reported a variety of improvised strategies. Insufficient access has led to a high risk of avoidable health conditions, including HIV and HCV transmission, bacterial infection, and overdose.