Abstract
Background:
New troublesome drug trends constitute a challenge for public health. Sweden has the second highest drug-related mortality rate in Europe. This calls for an investigation into the help-seeking attitudes of young adults to early middle-aged individuals asking how they would act in acute drug-related emergency or overdose situations.
Methods:
In total, 1232 individuals completed an online survey promoted on Sweden’s largest discussion forum Flashback.org. Their free-text responses were analysed according to inductively generated categories.
Results:
Around 60% of the sample would act as expected and contact emergency care without hesitation. However, approximately 32% of the sample showed palpable resistance and would put off seeking help and use emergency care only as a last resort due to, for example, fear of legal repercussions and stigma. Moreover, 8% displayed a total lack of confidence in public healthcare and would avoid it at all costs or entirely disregard it as an option due to the alleged risk of negative consequences and experienced restrictions on their personal freedom.
Conclusions:
While the inevitable criminalisation and stigmatisation associated with Sweden’s “zero tolerance” drug policy putatively serve as deterrents to drug use, our results demonstrate that these measures may also contribute to attitudes which discourage help-seeking. Such attitudes may at least partly explain the growing and comparatively high number of drug-induced deaths. Therefore, attitudinal and structural barriers to acute help-seeking in drug-related emergency situations should be acknowledged and investigated further in order to minimise harm.
Keywords
New troublesome drug trends and drug market characteristics have been observed both internationally and in Sweden during the past decade in particular. A global increase in drug use in general and the steadily higher potency of drugs with abuse liability constitute a challenge for public health (European Monitoring Centre for Drugs and Drug Addiction, EMCDDA, 2017a). Moreover, a number of cheap and readily available novel psychoactive substances, “legal highs”, with mostly undocumented effects, an ambiguous legal status, and imminent harm potential have flooded the market (EMCDDA, 2016). Although last-year and lifetime prevalence of drug use among the general population in Sweden are believed to be comparatively low (EMCDDA, 2018), data support the notion that drug use is increasing in Sweden. According to the EMCDDA (2017b), cannabis use among 16–34-year-olds is increasing, and wastewater analysis data from the capital Stockholm indicate that the use of amphetamine in the city is among the highest in Europe (Löve et al., 2018). The number of drug law offences in Sweden also increased progressively between 2000 and 2013 (EMCDDA, 2017b), as did drug-induced deaths; Sweden currently has the second highest drug-related mortality rate in Europe (EMCDDA, 2017b). Even though some of these increases may be explained by improved monitoring and reporting practices, a growing concern for public health undoubtedly exists. Considering the increasing mortality rates and the recent emergence of requests regarding potentially harmful novel benzodiazepines and fentanyl analogues to the Swedish Poisons Information Centre (EMCDDA, 2017b), help-seeking behaviours and attitudes related to acute drug emergencies need to be investigated more fully in order to minimise further harm.
The Swedish drug strategy for dealing with these challenges rests upon a “zero tolerance” policy, which means that it envisions a society entirely free from narcotics (Ministry of Health and Social Affairs, MHSA, 2016). Hence, the criminalisation of drug use – having drugs in your body – intends to prevent drug use, protect the public from the potentially harmful effects of drugs, and enable early interventions (MHSA, 2016). However, criminalisation may result in negative attitudes towards drug users (Ahern, Stuber, & Galea, 2007) and can lead to a situation where drug users are concerned about negative consequences and therefore avoid the public healthcare system and the authorities in general (Dahlberg & Anderberg, 2013; van Boekel, Brouwers, Van Weeghel, & Garretsen, 2013). For example, a previous study of ours documented cases where users turned to peers online rather than health professionals when experiencing acute drug-related reactions or side effects (Soussan & Kjellgren, 2014). Moreover, online drug users are known for their prominent counter-public health attitudes, general dissatisfaction with the healthcare system, and occasionally even resentment towards the authorities and institutions (Barratt, Allen, & Lenton, 2014; Soussan, Andersson, & Kjellgren, 2018). Several studies confirm that drug users experience attitudinal and structural barriers, such as stigmatisation and discrimination, to using healthcare services and therefore put off seeking help (Ahern et al., 2007; McCoy, Metsch, Chitwood, & Miles, 2001). A large body of research has established that a significant proportion of health professionals and the general public hold negative and moralistic attitudes towards drug users compared with other patient groups, which may compromise the provision of quality care (Harling, 2017; Henderson, Stacey, & Dohan, 2008; Lloyd, 2013; Skinner, Feather, Freeman, & Roche, 2007; van Boekel et al., 2013). It is also known that the majority of individuals with substance-use disorders neither seek nor receive help (Verissimo & Grella, 2017). In addition, help-seeking behaviours appear to be consistently less common among younger people and less common among men than among women (Möller-Leimkühler, 2002; Rickwood, Deane, Wilson, & Ciarrochi, 2005). This is particularly troublesome considering that users of especially novel drugs are younger men (Maxwell, 2014). Young people who experience stigma seemingly prefer self-reliance or online sources when investigating health- or drug-related issues of concern (Eurobarometer, 2011; Gray, Klein, Noyce, Sesselberg, & Cantrill, 2005; Gulliver, Griffiths, & Christensen, 2010).
Taken together, mutual mistrust and opposing negative views seem to prevail between drug users and health professionals (Merrill, Rhodes, Deyo, Marlatt, & Bradley, 2002), which may have profound and adverse effects on help-seeking behaviours and the recovery and social integration of drug users. However, most of the available data on the matter concern the treatment of problematic drug users diagnosed with substance-use disorder in non-emergency situations. Given the importance of studying “how care is provided to this underserved population and why their care poses challenges” (Henderson et al., 2008, p. 1336), our aim is to investigate and extend the knowledge pertaining to the help-seeking behaviours and attitudes of young adults to early middle-aged individuals in Sweden by surveying how they would act in an acute drug-related emergency or overdose situation.
Methods
Data collection
The data for this study were extracted from a larger data set collected through an online survey promoted on Sweden’s largest forum Flashback.org, which is publicly available and commonly visited for anonymous drug discussions. The participants were asked to answer the following open-ended question: Conceive of a situation in which you or a friend have used drugs, and during the acute influence of the drug you notice that something is wrong. An acute health hazard or an overdose has probably occurred. Would you seek help, and if so, how? Describe as elaborately as you can.
The survey was online between June and August 2017, and the raw data consisted of 25,553 words.
Participants
In total, 1232 individuals completed the survey. However, 143 participants chose not to reply to the question in focus for the present study, and another 24 participants’ responses were discarded due to answers which were found to be irrelevant (such as “I’m no amateur”). The survey was intentionally aimed at young adults to early middle-aged individuals, and it was required that the participants were aged 18 years or older. Hence, the range of the sample was 18–35 years with a mean age of 26.2 (median = 25, SD = 5.0). Males constituted 82.6% of the sample and females 17.4%. The average WHO-5 Well-being Index was 55.2 (SD = 22.7) and the average DUDIT score was 11.9 (SD = 9.6). The overall prevalence of current drug use according to the DUDIT scores was 87.6%, and the following risk levels were calculated in accordance with the DUDIT cut-off scores suggested by Berman, Bergman, Palmstierna, and Schlyter (2005): 23.9% (n = 255) of the respondents had no drug-related problems (total scores 0–5 for men and 0–1 for women); 64.1% (n = 683) had possible drug-related problems (6/2–24); and 11.9% (n = 127) were probably heavily dependent on drugs (≥ 25).
Analysis
The free-text survey responses were coded into categories created by the first author after reviewing all responses systematically and repeatedly with a data-driven bottom-up approach undertaken with as little bias as possible. Next, the second author independently reviewed the categorised responses, and discrepancies between the authors were resolved by discussion. In cases where the same participant outlined different responses depending on factors such as if the situation concerned themselves or others (e.g., “Call the emergency number for friends, myself I welcome death”), we coded the response strictly on the basis of the overall attitude to public healthcare, which meant that this participant was categorised as willing to contact public healthcare rather than avoiding it.
A variance test analysis was conducted to compare the effect of the type of the categorical help-seeking attitude on the WHO-5 Well-being Index and the DUDIT scores respectively. Non-parametric Chi-square tests were calculated comparing the frequency of the type of the categorical help-seeking attitude in DUDIT risk-level categories (reported in the section Participants) and in men and women.
Ethical considerations
Before taking part in the survey, the respondents were thoroughly informed about the research, its purpose, and that participation was entirely voluntary. The sample was self-selected, and the respondents could terminate participation at any time without specifying why as long as the survey was not submitted. No explicit identity markers were requested so that the respondents could remain unidentified. In order to participate, the respondents were asked to confirm that they were between 18 and 35 years of age. The survey responses and data have been treated with integrity so that only authorised people participating in the research have access to it. The study was ethically approved by the Uppsala Ethical Review Board, dnr 2017/156.
Results
The following three types of help-seeking categories emerged during the analysis of 1065 participants’ free-text survey responses on how they would act in an acute drug-related health hazard or overdose situation: (1) 60.4% of the participants would most likely contact public healthcare and the emergency services without hesitation, (2) 31.6% were also prepared to contact public healthcare and the emergency services but with considerable resistance and hesitance, or as a last resort after attempting other solutions, and (3) 8.0% of the participants would apparently avoid public healthcare or entirely disregard it as an alternative.
An analysis of variance showed that the effect of type of help-seeking category on the reported DUDIT score was not significant, (F(2, 1062) = 2.63, p = .072). Correspondingly, the same effect on the reported WHO-5 Well-being Index was not significant, (F(2, 1062) = .145, p = .865). This was verified by the result of the Chi-square test comparing the frequency of type of categorical help-seeking attitude in DUDIT risk-level categories; no significant interaction was found (χ2 (4) = 8.55, p = .073). Likewise, no significant interaction was found when calculating the same frequency in men and women, (χ2 (4) = .195, p = .907).
Contact public healthcare without hesitation
This category summarises the participants whose immediate response would be to contact the emergency care services without hesitation and regardless of consequences. For these participants, calling the emergency services seemed to be self-evident, obvious, and associated exclusively with confidence rather than resistance or resentment. The characteristic sentiment was that a potentially life-saving call to the emergency care services by far overshadowed other considerations. Alternative options were seldom mentioned or seemed inconceivable. The participants also claimed they would be truthful about the course of events and everything pertaining to the situation such as drugs used, location, and the identities of the persons involved. In essence, they appeared to equate a drug-induced emergency situation with any other type of emergency situation, and would act accordingly by calling the emergency services without hesitation.
Some illustrative quotations: Call the emergency services, what else is there to do? I have great confidence in the healthcare system and I would never hesitate to seek emergency care regardless of the reason. Call the emergency services and be totally honest. No point in dying because of shame or fear. Obviously call the emergency care if I thought that a threatening situation occurred.
Contact public healthcare with resistance or as a last resort
This category incorporates the participants who were prepared to contact the emergency care services but under certain conditions, with reservations, or as a last resort after attempting several other solutions. This group appeared to treat a drug-induced situation differently from other emergency situations. They were more hesitant and appeared to take a range of perceivably negative consequences into account before contacting the emergency care services, which appeared as notable procrastination about help-seeking behaviours. The most commonly mentioned barrier was concern about the police arriving with or before the healthcare professionals, and the entailing risk of legal repercussions. They were also worried about being subjected to stigmatisation, regular drug screening tests, house searches, child custody inquiries, and retracted medical prescriptions. Rather than contacting the emergency services immediately they would carefully deliberate to assess the severity of the situation and handle it by other means for as long possible. Calling the emergency services was associated not only with resistance but occasionally even resentment, and it was often depicted as a last resort following a range of other actions. Before calling the emergency care services, the participants would resort to self-treatments and “riding it out” strategies, contacting friends, family, and other confidants, seeking advice or information online, or would go to the hospital on their own in order to avoid police involvement. They also described how they would use other drugs as countermeasures to the initial drug problem. In the event of having to reluctantly contact the emergency services, this group of participants declared that they were inclined to lie or withhold information about drug use, locations, and identities of the persons involved. They also said that they would run from the scene or take the affected person to a neutral place outside of personal homes and locations which could compromise their anonymity.
Some illustrative quotations: I would call the emergency services, however, I would hesitate and postpone more than if it concerned an accident. The emergency services are the absolutely last way out, a telephone number one shies away from as long as possible and maybe even a little longer. Only if it is entirely certain that the person’s life is in danger since the police could be involved with severe consequences as a result. No, not immediately since me and my friend risk legal repercussions, fines, and all that comes with that, so I would without a doubt wait. If no other alternative exists I would call the emergency services as a last resort. If I had to call the emergency services for a friend I would call from a concealed number and not give my name, and I would leave the location to avoid detection. I would check information online and then, if I felt that there is really no other way out, call an ambulance.
Avoiding public healthcare
This category contains the participants who said that they would avoid emergency care services at all costs and those who described a response which entirely disregarded public healthcare as a possibility. This group appeared to be full of resentment or fear of public healthcare, the authorities, and institutions. They were also characterised by a total lack of confidence in the healthcare system and unwillingness to, in their eyes, degrade themselves by exposing themselves to the derogatory views and actions of society. In many cases, the participants said that they would actively avoid the emergency services and rather face the risk of negative health outcomes over stigmatisation, criminalisation, and other perceivable negative consequences such as losing their driving licence or child custody. It appeared that they experienced the potentially negative outcomes as heavy restrictions on their personal freedom, without which their life was depicted as not worth living. Instead of resorting to emergency care they would handle the situation on their own by self-treatment strategies, contacting friends, family, and other confidants, seeking advice and information online, or simply “riding it out”. They also mentioned that they avoided the need for public health through proactive measures such as being well-informed about drugs, risks, and possible countermeasures to a hazardous situation. Several participants also declared having ample experience, knowledge, and training to handle drug-related crisis situations and not being in need of emergency care.
Some illustrative quotations: No, this has happened and we were too afraid of the police arriving at the hospital and we never called an ambulance. No, I wouldn’t call. If I die I die. All of us are going down that road sooner or later anyway. Seek information online, never contact with the authorities. I would probably let it go where it goes, what is a life without freedom and integrity? Never, I would be stigmatised and locked in a system which is almost impossible to get out of since they do everything in order for one to have a relapse and show a positive drug test. I would not turn to public health. Rather be dead than registered in a medical record. I would seek effective countermeasures in online drug discussion forums. I wouldn’t seek help. I would have felt enormous shame if I had sought help.
Discussion
We have sought to investigate and extend the knowledge pertaining to the help-seeking behaviours and attitudes of 18–35-year-old individuals in Sweden by surveying how they would act in an acute drug-related emergency or overdose situation. The results show that around 60% of the sample would respond just like in any other type of emergency situation by immediately contacting public healthcare and the emergency services without hesitation. However, approximately 32% would do the same although with palpable resistance and hesitation towards public healthcare and the emergency services. This group was notably concerned about negative consequences such as legal repercussions and stigma, and would put off help-seeking and resort to self-treatment strategies for as long as possible. Around 8% followed the same line of resistance and displayed not only resentment but total lack of confidence in the authorities in general, and would avoid public healthcare altogether or entirely disregard it as an alternative regardless of the outcomes, because the risks of, in their eyes, negative consequences and heavy restrictions on their personal freedom were too big. The findings confirm that avoidance of public healthcare and aggravating mistrust and negative attitudes towards health professionals and law enforcement appear to prevail not only in non-emergency drug treatment situations with problematic users (e.g., Ahern et al., 2007; Harling, 2017; McCoy et al., 2001; Van Boekel et al., 2013) but during acute drug emergencies with all types of users as well. Interestingly enough, no significant differences in attitudes were found between men and women, persons with varying degrees of risk-level drug use (DUDIT), or persons with varying degrees of emotional well-being (WHO-5), which indicates that these attitudes are general to some extent, and not limited solely to problematic users.
It is alarming that a substantial proportion of the investigated individuals hold attitudes which may lead to non-help-seeking or delaying help-seeking in drug-related emergency or overdose situations where urgent and professional help is essential. Among other things, the participants were prone to withhold vital information from health professionals about the cause of events or to self-treat drug emergencies with other illicit drugs at hand, which could obstruct proper care or induce further risks. The main reason for resorting to friends, online sources, or “riding it out” strategies rather than the emergency care services was a fear of legal repercussions and the police arriving with or before the health professionals. Data from the US and the UK show that drug users are increasingly dealt with as a criminal problem rather than a health problem (Ahern et al., 2007), and drug users’ contact with the police was experienced as coercive and adversarial (Lloyd, 2013). A stricter drug policy trend can also be observed in Sweden, where personal drug consumption was criminalised in 1988 and “imprisonment was added to the scale of sanctions for personal use in 1993” (MHSA, 2016, p. 7) as a “prerequisite for the police to be able to take drug tests without a subject’s consent” (Tham, 2009, p. 433). While the Swedish government allegedly has received no indications that criminalisation of personal drug use would act as a barrier to help-seeking among problematic users (MHSA, 2016), we would like to emphasise that the results of our study indicate the opposite, namely that fear of criminalisation and stigmatisation would prevent a significant proportion of drug users from seeking help in emergency or overdose situations.
The participants’ attitudes may at least partly explain the growing and comparatively high number of drug-induced deaths during the past decade despite the otherwise low drug-use prevalence in Sweden (EMCDDA, 2017b). While inevitable tools such as criminalisation and stigmatisation associated with Sweden’s “zero tolerance” drug policy putatively serve as deterrents to drug use (MHSA, 2016), our results demonstrate that these measures may also contribute to attitudes which discourage help-seeking. Drawing upon the theory of psychological reactance (Crossley, 2002), health promotion attempts perceived as threatening to an individual’s freedom will result in resistance and internal pressure to re-establish the lost freedom by rebelling or acting in opposition to the health promotion efforts. Several examples of such counter-public health attitudes, health detrimental behaviours, and counterintuitive “boomerang effects” of well-intended public health promotion initiatives have previously been documented both in relation to drug use (Barratt et al., 2014; Soussan et al., 2018) and other areas relating to safer sexual practices amongst gay men (Crossley, 2002) and help-seeking among young people with mental health problems (Gulliver et al., 2010; Rickwood et al., 2005). The phenomenon of psychological reactance perhaps explains the significant number of participants (40%) with derogatory, avoiding and potentially life-threatening attitudes towards public healthcare, especially when considering their frequently mentioned concern about negative consequences and their explicit need to preserve personal freedom. In addition, previous research has established that negative and moralistic attitudes towards drug users exist among health professionals, who also displayed less empathy, motivation, and adequate knowledge and training in caring for this particular patient group (Harling, 2017; Henderson et al., 2008; Lloyd, 2013; Skinner et al., 2007; van Boekel et al., 2013). Therefore, both attitudinal and structural barriers to acute help-seeking in drug-related emergency situations should be acknowledged in order to minimise harm, and efforts to deflate fears about drug users should be undertaken in order to reduce the mutual mistrust between drug users and health professionals (Lloyd, 2013; Merrill et al., 2002). Moreover, the relative risks and benefits of the Swedish drug policy model, including criminalisation and stigmatisation, should be investigated further, especially when considering the recent and emerging new drug trends and drug market characteristics.
Limitations and strengths
Some limitations and strengths should be noted. First, we do not know whether these results can be generalised to a general population of drug users. We believe the data from users on flashback.org mirror an important view held by drug users who use online resources. Recent research has concluded that online drug forums are a valid and reliable source of information for identifying temporal trends and demographics (Paul, Chisolm, Johnson, Vandrey, & Dredze, 2016). Our focus on younger persons aged 18–35 years might not be fully representative, since the mean age for drug deaths is about 40 years. But focusing on younger persons is important, because earlier research has drawn attention to the notion that help-seeking behaviours in general appear to be consistently less common among younger people (e.g., Rickwood et al., 2005), while older persons (aged 50 years and older) show increased rates of help-seeking for substance-related problems (e.g., Sacco, Kuerbis, Gogea, & Bucholz, 2013). In addition, younger persons are more prone to using a steadily increasing number of novel psychoactive substances which are legally ambiguous and have imminent harm potential due to their unknown toxicological profiles and erratic effects.
Second, we do not know whether the responses are truthful. The quality and validity of anonymous questionnaire data can always be discussed. However, earlier research involving online drug discussion forums has indicated data to be considered free from exaggerated drug romanticising or distorting bias, and more about safety and harm reduction (e.g., Soussan & Kjellgren, 2014; Wood & Dargan, 2012).
Third, we do not know whether these attitudinal barriers to seeking help have explanatory value for the high level of drug-related mortality in Sweden, but we believe that receiving acute medical help during a drug overdose is of utmost importance for minimising drug deaths. The probably complex reasons for drug-related deaths cannot be assessed using an online questionnaire only, although our results contribute a perspective that needs to be further explored. For example, it would be fruitful to investigate whether reduced involvement of enforcing authorities during drug-related seeking of medical care would affect help-seeking patterns positively.
As the stigma surrounding drug use seems to be prevalent, it might be that the participants reveal their attitudes to a larger extent when their identities are concealed, as in this study. It can be assumed that their attitudes of suspicion against authorities and healthcare professionals are spread on the online forum, thereby affecting and influencing other persons. Therefore, we assess their responses as valuable for providing an insight into the hidden “drug culture” and its values. Exploring the stigma surrounding drug use might be another important future research area.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Public Health Agency of Sweden, (grant/award number: 0234-2016), County Council of Värmland (Landstinget i Värmland), (grant/award number: LIVFOU-765801).
