Indiana University-Purdue University Indianapolis (IUPUI)

Society's view of addiction problems and their treatment is constantly evolving. This study highlights the experience of counselors, nurses and others with social worker education of the structure of the activities, the practical work and the social work in a medical context. Based on previous research and theoretical concepts, this qualitative study is conducted to gain a more in-depth insight into the practical work of the professions and to create an understanding of the structure of the organization. The reason for conducting this study is also to see similarities and differences in how the employees of the syringe exchange activities experience what social work looks like in a medically permeated workplace. To obtain the empirical data, semi-structured interviews were conducted with seven different active professions at different needle exchange facilities in Sweden. The results of the study highlight, among other things, the professions' flexibility and broad scope of action, the importance of collegial collaboration for knowledge exchange and support, and the laws and regulations that the activities need to relate to. Conclusions that could be drawn were that the social work at the syringe exchange facilities is also a pervasive part of the work of the professionals and the interventions offered. Similarly, laws and regulations are perceived to be somewhat flexible according to the interviewees and many times solutions are found to ensure the best interests of the patient. Another conclusion is that large parts of the professionals' experiences of the activities support the goal and purpose of the syringe exchange activities in Sweden, i.e. to motivate people to receive care and treatment.

Studien undersöker förekomsten av brukarinflytande vid implementeringen av det första sprututbytet i Stockholms län. I studien ges en bakgrund till Sveriges narkotikapolitik och hur dess utvecklingen har sett ut från 70- talet fram till idag. I bakgrunden till studien presenteras ett governace-perspektiv på brukarinflytande och de deliberativa processer där brukarinflytande är en naturlig del av policyprocessen. Syftet med studien är undersöka förekomsten av brukarinflytande i implementeringsdelen av den besluts- policyprocess som ledde fram till sprututbytets öppnande i april 2013. Studiens teoretisk ramverk består av teorier som ifrågasätter givenheten i governance-synsättet på brukarinflytande genom hänvisning till svårigheter med aktörskap och risken med konstruerat brukarinflytande. Forskningsstrategin som studien utgår ifrån är intervjuer med utvalda respondenter som har varit delaktiga vid implementeringen av sprututbytet samt brukarorganisationer som representerar och företräder sprututbytets målgrupp. Resultatet av studien visar på en svag förekomst av brukarinflytande vid implementeringen av sprututbytet. Det brukarinflytande som kan anses har förekommit har varit på en individuell nivå och icke-formaliserat. I analysen presenteras tre möjlig förklaringar till den svaga förekomsten av brukarinflytande vid implementeringen av sprututbytet samt en analys om svårigheter med aktörskap vid implementeringen kopplat till studiens teoretiska ramverk. / This study examines the occurrence of user influence during the implementation of the first Needle and Syringe exchange Programme (NSP) in Stockholm County. The survey in his study consists of interviews conducted with persons that have been involved during the process and debate around the NSP in Stockholm County. The interviews have been conducted with two different groups of actors: User organizations and public actors. The first group called user organizations consists of actors from three different user organizations representing and organizing the target group for the NSP. The second group called public actors consists of public actors which have been involved under and/or before the implementation of the NSP in Stockholm County. The study contains a description of the background of NSPs in Sweden. The study describes the development of the Swedish drug policy from 1970 until today. Further it covers the development of the NSPs in other parts of Sweden as well as the development of harm reduction as a general strategy for drug addiction management. Several definitions to the terms user and user influence are presented. Four are conventional definitions of the term user, together with a fifth one which is then used within in the context of the study. The study presents definitions of the term user influence by a model dividing user influence in three categories: individual level, operational level and system level. Another division of the term user influence presented is formalized and non-formalized user influence. These different classifications are used in the analysis of the results. The study also presents a background to the governance view on user influence as a natural and unproblematic part in the policy process. The theoretical framework in the study consists of two parts: The first part questions governance and the given of user influence within a policy process. The study highlights the problems with a governance view on actorhood and user influence. The second part of the theory chapter presents a model for the policy process. The policy process is described in five stages: Initiation, processing, decision making, implementation and evaluation. The results of the survey show little occurrence of user influence during the implementation of the NSP. By using the classification with the three different levels of user influence the result is that the occurrence of user influence found in the investigation has the characteristics of individual level user influence. The study also shows that the user influence found can be classified as non-formalised influence. The analysis first discusses the factors of why there has been little occurrence of user influence during the implementation of the NSP and proposes three different plausible explanations: Politically sensitive question, structural difficulties and users view was already known. The analysis also discuss the problem with a governance view on actorhood and user influence in relation to the study. The study concludes that there has been little occurrence of user influence during the implementation of the NSP in Stockholm County and that the occurrence of user influence found can be classified as individual level user influence, with one plausible exception.

This dissertation presents three chapters of contemporary research in environmental and development economics. Each chapter echoes a common theme, in that achievement of regional goals constitute 'Wicked Problems' and that the approaches that parties may take to address these specific regional goals may have complex interactions with other regional goals. Decision-making, cost analysis, and multipurpose efficacy of the approaches that regional parties may take to achieve goals are evaluated in environmental and development contexts and implications for program analysis and policy design are discussed. The first chapter of this dissertation seeks to understand how regulated parties, i.e. Municipal Separate Storm Sewer Systems (MS4s), choose from the strategies at their disposal to achieve compliance with their Chesapeake Bay Total Maximum Daily Load (TMDL) obligations. To address declining Chesapeake Bay water quality, the United States Environmental Protection Agency (EPA) set extensive nutrient and sediment reduction goals under the 2010 Chesapeake Bay TMDL. Virginia has responded by passing along explicit nutrient and sediment reduction requirements to its MS4s, which can choose from a variety of urban stormwater, land use change, source control, and restoration practices to achieve reductions toward these requirements. MS4s in Virginia have also been granted flexibility to achieve reduction requirements through purchase of nutrient and sediment credits toward requirements through trade. In spite of the cost-savings that these credits provide, MS4s' interest in trading for these credits has been low. MS4s instead generally engage in onsite nutrient and sediment reduction themselves, in spite of the high costs of doing so. In response to low interest in trade, case analysis of MS4s' Bay TMDL compliance behavior and semi-structured interviews are conducted to better understand the role of trade in compliance strategy and the reasons for its non-use. Findings reveal that the Virginia MS4s studied typically choose to implement onsite urban stormwater practices, source control practices, and restoration practices in order to generate long-lasting local benefits, like erosion control, flood risk reduction, and progress toward local TMDL obligations, alongside reductions toward the Bay TMDL. MS4s refrain from term credit purchases out of concern over future availability and refrain from perpetual credit purchases because they have been able to use funding sources to achieve reductions from long-lasting onsite practices at similar per-pound costs, while also receiving local benefits. Implications are that supply-side efforts to support trade markets may not generate the level of activity expected, given that would-be buyers have generally limited interest in trade as a compliance strategy. The second chapter studies the degree to which the practices used to meet local TMDL water quality obligations contribute to Bay TMDL compliance for the Loudoun County MS4. Linear programming is used to estimate the minimal cost of achieving Bay compliance in addition to local obligations through representative nutrient and sediment reduction strategies. The model estimates that Loudoun County MS4 faces substantial costs just to meet local water quality goals ($11 million/yr). Since many of the actions taken to meet local water quality goals also generate pollutant reductions to the Chesapeake Bay, adding Bay TMDL obligations adds 0.2%, 3%, and 32.9% to these costs, depending on the water quality trading used to reach Bay TMDL compliance. Findings shed additional light on Chapter 1's goal of investigating the role of trade by explaining low interest in trade as stemming from heavy local water quality needs. Implications are that the burden imposed by the Bay TMDL may not be as high as generally thought. The third chapter shifts focus to the Opioid Crisis to evaluate the efficacy of Syringe Exchange Programs, best known for their efforts to prevent bloodborne illness transmission, at achieving their secondary intervention goal of preventing opioid overdose. While research has established that Syringe Exchange Programs, or SEPs, are effective at preventing bloodborne illness, little focus has been given to their ability to prevent fatal overdose, which they aim to do by engaging in intervention practices like naloxone and fentanyl test strip distribution. In response for need for understanding of Syringe Exchange Programming's impact on overdose, fixed effects analysis is used to empirically study the impact of county-level SEP in North Carolina following the state's 2016 SEP legalization. Need-based programming complicates analysis and likely biases findings of the impact of SEP on overdose upward. Regardless, findings consistently fail to find that SEP has a significant effect on fatal overdose from four categories of opioids, which should reduce concerns in recent literature that they may increase overdose death. Implications are that, since SEPs have a richly documented history of saving lives through the prevention of bloodborne illness and do not appear to increase overdose, contrary to findings in other work, policy makers should continue to incorporate SEP into their portfolio of strategies used to address the Opioid Crisis. / Doctor of Philosophy / This dissertation presents three chapters of contemporary research in environmental and development economics. Each chapter echoes a common theme, in that achievement of regional goals constitute 'Wicked Problems' and that the approaches that parties may take to address these specific regional goals may have complex interactions with other regional goals. Decision-making, cost analysis, and multipurpose efficacy of the approaches that regional parties may take to achieve goals are evaluated in environmental and development contexts and implications for program analysis and policy design are discussed. The first chapter of this dissertation seeks to understand how regulated parties, i.e. Municipal Separate Storm Sewer Systems (MS4s), choose from the strategies at their disposal to achieve compliance with their Chesapeake Bay Total Maximum Daily Load (TMDL) obligations. To address declining Chesapeake Bay water quality, the United States Environmental Protection Agency (EPA) set extensive nutrient and sediment reduction goals under the 2010 Chesapeake Bay TMDL. Virginia has responded by passing along explicit nutrient and sediment reduction requirements to its MS4s, which can choose from a variety of urban stormwater, land use change, source control, and restoration practices to achieve reductions toward these requirements. MS4s in Virginia have also been granted flexibility to achieve reduction requirements through purchase of nutrient and sediment credits toward requirements through trade. In spite of the cost-savings that these credits provide, MS4s' interest in trading for these credits has been low. MS4s instead generally engage in onsite nutrient and sediment reduction themselves, in spite of the high costs of doing so. In response to low interest in trade, case analysis of MS4s' Bay TMDL compliance behavior and semi-structured interviews are conducted to better understand the role of trade in compliance strategy and the reasons for its non-use. Findings reveal that the Virginia MS4s studied typically choose to implement onsite urban stormwater practices, source control practices, and restoration practices in order to generate long-lasting local benefits, like erosion control, flood risk reduction, and progress toward local TMDL obligations, alongside reductions toward the Bay TMDL. MS4s refrain from term credit purchases out of concern over future availability and refrain from perpetual credit purchases because they have been able to use funding sources to achieve reductions from long-lasting onsite practices at similar per-pound costs, while also receiving local benefits. Implications are that supply-side efforts to support trade markets may not generate the level of activity expected, given that would-be buyers have generally limited interest in trade as a compliance strategy. The second chapter studies the degree to which the practices used to meet local TMDL water quality obligations contribute to Bay TMDL compliance for the Loudoun County MS4. Linear programming is used to estimate the minimal cost of achieving Bay compliance in addition to local obligations through representative nutrient and sediment reduction strategies. The model estimates that Loudoun County MS4 faces substantial costs just to meet local water quality goals ($11 million/yr). Since many of the actions taken to meet local water quality goals also generate pollutant reductions to the Chesapeake Bay, adding Bay TMDL obligations adds 0.2%, 3%, and 32.9% to these costs, depending on the water quality trading used to reach Bay TMDL compliance. Findings shed additional light on Chapter 1's goal of investigating the role of trade by explaining low interest in trade as stemming from heavy local water quality needs. Implications are that the burden imposed by the Bay TMDL may not be as high as generally thought. The third chapter shifts focus to the Opioid Crisis to evaluate the efficacy of Syringe Exchange Programs, best known for their efforts to prevent bloodborne illness transmission, at achieving their secondary intervention goal of preventing opioid overdose. While research has established that Syringe Exchange Programs, or SEPs, are effective at preventing bloodborne illness, little focus has been given to their ability to prevent fatal overdose, which they aim to do by engaging in intervention practices like naloxone and fentanyl test strip distribution. In response for need for understanding of Syringe Exchange Programming's impact on overdose, fixed effects analysis is used to empirically study the impact of county-level SEP in North Carolina following the state's 2016 SEP legalization. Need-based programming complicates analysis and likely biases findings of the impact of SEP on overdose upward. Regardless, findings consistently fail to find that SEP has a significant effect on fatal overdose from four categories of opioids, which should reduce concerns in recent literature that they may increase overdose death. Implications are that, since SEPs have a richly documented history of saving lives through the prevention of bloodborne illness and do not appear to increase overdose, contrary to findings in other work, policy makers should continue to incorporate SEP into their portfolio of strategies used to address the Opioid Crisis.

Bakgrund: Personer som injicerar droger har i tidigare studier visat sig ha en lägre livskvalitet än andra populationer och många lider av psykisk ohälsa. Spridning av blodsmittor som hiv och hepatiter och andra blodburna infektioner kan vara en risk vid injicering. Tillgång till sterila sprutor och kanyler genom sprututbyte är en åtgärd för att minska spridning av infektionssjukdomar. Centralt för psykiatrisk omvårdnad, i likhet med harm reduction, är att värna mänskliga rättigheter, att erbjuda vård på lika villkor och stärka förmågan till egenvård. Syfte: Syftet med denna studie var att undersöka om livskvalitet hos personer som injicerar droger förbättras över tid efter inskrivning på Stockholms sprututbyte samt om det fanns någon skillnad mellan könen. Metod: Denna studie genomfördes som en prospektiv icke-experimentell longitudinell kvantitativ studie. Urvalet bestod av besökare på Stockholms sprututbyte som valde att delta. Studiedeltagarna svarade på livskvalitetsenkäten EQ-5D vid tre mättillfällen. EQ-5D mäter graden av tillfredsställelse i fem dimensioner (indexpoäng) samt innehåller en global skattning av nuvarande hälsotillstånd (EQ VAS). Förändring över tid analyserades med hjälp av ANOVA för upprepade mätningar. Resultat: Resultatet visade på en signifikant förbättring av livskvalitet över tid avseende EQ VAS för hela gruppen. Resultatet visade vidare att kvinnor skattade sitt nuvarande hälsotillstånd EQ VAS signifikant lägre än män. Slutsats: Deltagande i sprututbyte verkar ha betydelse och inverka positivt på hälsorelaterad livskvalitet hos personer som injicerar droger men mer behöver studeras för att få en bredare kunskap om vad det är som gör att det förhåller sig så. / Background: People who inject drugs have shown in previous studies to have a lower quality of life than other populations and many suffer from mental illness. The spread of blood infections such as hiv and hepatitis and other blood borne infections can be a risk when injecting. Access to sterile syringes and needles through syringe exchange is a measure to reduce the spread of infectious diseases. Central to psychiatric care, like harm reduction, is to protect human rights, to offer care on equal terms and to strengthen the capacity for self-care. Aim: The purpose of this study was to investigate whether the quality of life of people who inject drugs improves over time after enrollment in Stockholm needle and syringe exchange program and if there were any gender differences. Method: This study was conducted as a prospective non-experimental longitudinal quantitative study. The selection consisted of visitors at the Stockholm exchange who chose to participate. The study participants answered the quality of life questionnaire EQ-5D on three occasions. EQ-5D measures the degree of satisfaction in five dimensions (index points) and contains a global estimate of the current state of health (EQ VAS). Change over time was analyzed using ANOVA for repeated measurements. Results: The results showed a significant improvement in quality of life over time with regard to EQ VAS for the entire group. The results further showed that women estimated their current state of health EQ VAS significantly lower than men. Conclusions: Participation in needle and syringe exchange programs appears to have significance and a positive impact on health-related quality of life but further studies needs to gain a broader knowledge of what it is that makes it so.

About 35 years ago the WHO advocated that countries with injecting drug users should introduce the so-called needle exchange programs (NEP) to curb the spread of infection by blood-borne diseases. In Sweden the first NEP started 1985 in Lund, but the program was extremely controversial in a country with such a restrictive drug policy like Sweden. The study you are about to read shall process this controversy, when a NEP opened in Stockholm, by analyzing the articles published in the newspapers Dagens Nyheter and Svenska Dagbladet. By using discourse analysis as a processing tool we’ll try to see the difference between the two chosen newspapers. We will identify and analyze the different participant’s, such as doctors, politicians, user associations and media, arguments in the needle exchange issue.   Our results show that the liberal DN articles were supportive of the NEP and that they considered it to be an infectious disease control issue. The liberal conservative newspaper SvD had a different view of the issue and considered NEP to be a question about drug policy. Even after the decision was made the city had problems to find suitable premises for the NEP to operate from.

The aim of this thesis is to describe the users visiting the syringe exchange clinic in Malmö with respect to what characterises the group, how they utilize the services of the clinic and how their patterns of participation relate to risk behaviour, physical and mental health and social development. The heterogeneity of the group has been captured by the use of Stimsons dimensions “integration in majority society” and “involvement in sub-culture”, yielding four different groups of syringe exchangers: “stables”, “loners”, “two-worlders” and “junkies”. The study rests on two sources of data: a register from the clinic including all syringe exchangers that have visited the clinic between 1989 and 2003, altogether 3660 individuals, and an interview of visitors at the clinic during 1995, including 496 persons. The results show that syringe exchangers, compared to other persons with severe addiction in Malmö, to a larger extent use amphetamine as their drug-of-choice, are older and inject more irregularly. The population visiting the clinic is heterogeneous with respect to integration in society and involvement in sub-cultures. The group classified as junkies do, as expected, display the highest inclination to share syringes and needles with other and hence have the most advanced risk behaviours. As to utilization of the programme, the results show that the longer the syringe exchangers stay in the programme, the more frequent they visit it. Also with respect to utilization-patterns, we find substantial variations within the studied group. Five categories are discernible: drop-in visitors with only one or two visits, sporadic visitors who in spite of contacts over a number of years never really establish a regular contact, intermittent visitors who have had contact over several years but display a very irregular visiting pattern, regular visitors who relatively fast establish a consistent contact with visits between uniform time intervals and frequent visitors who tend to stay longer than others and visit the clinic more often. Another aspect of utilization is to what extent the distribution of needles and syringes cover the needs of the visitors. With a strict definition of need, only a minority manages to cover their needs, but if we accept a more extensive individual re-use, around 90 percent of the average need is covered. Data also reveals that a very high proportion of the users on at least one occasion have visited the programme without syringe exchange taking place or any complementary service delivered. Basically these visits seem to be of a more social nature, reinforcing the contacts between the staff and the visitors. Data do not give any clear support for the basic assumption that syringe exchange reduce the incidence of HIV or hepatitis. Recent sharing of utensils or low coverage of syringe need through the programme do not predict a higher infection risk. Instead we find that the social contacts with the staff (without syringe exchange) function as a predictor of lower incidence. This indicates that the mechanisms may be more complex than just related to the provision of clean needles and syringes. The result shows that integration increase over time while sub-cultural involvement decreases. However, the patterns for different groups are very diverse and we find no evidence that more frequent contacts as such are related to increased integration. There is however, some evidence that social visits are positively related to increased integration. No support could be found for the assumption that the programme increases the number of severe addicts.