Introduction

This report deals with the labour market integration of people with alcohol and substance use problems in the Nordic countries of Denmark, Finland, Greenland, Iceland, Norway, and Sweden. Labour market integration of vulnerable groups has been a prominent focus within the Nordic countries throughout the recent decades (Bratsberg et al., 2017). Consequently, this emphasis has engendered substantial scholarly inquiry, but relatively scant attention has been directed exclusively to the labour market integration of individuals with alcohol and substance use problems, a distinctive vulnerable cohort in the Nordic context.

It is commonly acknowledged that labour market participation has benefits for health and wellbeing (Rosner et al., 2020). Work plays a significant role in providing a sense of meaning (Reinertsen, 2015), and favourable mental states such as coping, self-esteem, and self-realisation are intricately linked with employment. Moreover, work shapes daily routines and plays an important role in establishing social networks, fostering friendships, and encouraging active involvement (Gruber et al., 2014). Additionally, it contributes to both financial and social advantages, which in turn enhance the capacities associated with social participation and active citizenship (Berkman, 2014). These benefits arguably apply to individuals struggling with alcohol and substance use, too, but they are often excluded from working life (Rognli et al., 2023). Furthermore, unemployment poses a significant challenge to the financial sustainability of modern welfare states. Integrating individuals with substance use problems could thus be seen as a means to alleviate these challenges and enhance the longevity of the welfare state (Ko, 2020). 

The overarching aim of this report is to share Nordic experiences and enhance understanding about the integration of individuals with alcohol and substance use problems across the Nordic region. More specifically, to identify any particularly successful methods and interventions for labour market integration of this particular target group. The report also aims to shed light on lessons that can be drawn from organising and delivering these services. 

The country profiles are based on overarching research questions and associated dimensions and have been authored by researchers and experts from Denmark, Finland, Greenland, Iceland, Norway, and Sweden. These profiles contribute individual knowledge about each Nordic country, which is also used in the case-oriented comparative analysis and to illuminate the overall purpose of the report.

The overarching research questions are: 

The overarching research questions have led us to distinguish three dimensions as the basis of the country profiles. See table 1 for a detailed description and operationalisations of the dimensions. While all authors have employed these dimensions to guide their country profiles, there are variations in which components they have emphasised in their work.

Historically, what are now known as substance use disorders (SUDs) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) have appeared under a myriad of labels. Several of these terms are nowadays considered stigmatising (Spiehs & Conner, 2018). For example, it is widely acknowledged that the terms alcoholic, abuser, addict, and junkie are stigmatising and are not recommended in professional and scholarly contexts. It is assumed that stigmatising terms can negatively impact the quality of care and contributes to a negative bias among the general public (Ashford et al., 2019).    

While the term SUDs is established in professional and scholarly contexts, the term have slightly been adjusted for its use in this report. The term ‘substance use problems’ is used, because the target group includes those who have a problematic use of alcohol and/or other substances (such as illicit drugs or prescription medications) but who do not necessarily qualify for a diagnostic disorder. Indeed, several of these individuals do have a SUDs diagnosis, but not all. While some of these are currently in treatment or have had experience with treatment, others do not. The term substance use problems is conceptualised in relation to labour market exclusion and is defined as ‘individuals who have been excluded from, or struggle to be included into the labour market partly or completely due to alcohol and or substance use’. These individuals can have varying degrees of alcohol and substance use and hence different struggles regarding labour market integration. Some of these individuals have been or are currently in medical or other kinds of treatment for their use, while others do not have such a treatment track. 

Furthermore, as indicated above, some individuals face challenges associated with alcohol, which is a legal substance, whereas others struggle with illicit drugs such as cannabis and heroin. Additionally, there are those who exhibit problematic usage patterns concerning prescription medications, such as opioids and benzodiazepines. Although the consumption of all psychoactive substances has the potential to generate significant challenges for the individual, additional burdens are imposed upon them when they engage in the consumption of illicit substances. These include legal consequences, social stigma, and unintended consequences of drug policies (Moskalewicz et al., 2021).  

Substance use problems are not typically classified as a traditional disability in the same way as physical, sensory, cognitive, or developmental disabilities (United Nations Enable, 2006). However, because substance use can significantly impact a person’s functioning in relation to daily life and working life, it could in some cases be viewed as a chronic condition comparable to other types of disabilities (Goodwin & Sias, 2014).

In summary, individuals with substance use problems comprise a highly diverse and heterogeneous group, encompassing a wide range of backgrounds, experiences, and underlying factors contributing to their struggles. Nevertheless, they share a commonality in having a problematic connection with various substances, which, to varying extents and through diverse mechanisms, creates obstacles to their active engagement in the workforce. 

Throughout this report, the term substance use problems will be used as consistently as possible in relation to the target group as depicted above. However, where a different term is used by the source being referenced, the terminology utilised in that source will be adhered to.

In general, the Nordic labour market is characterised by high employment rates, relatively low wage differences, a high education level, and high adaptability. People who have difficulties getting into work often have a combination of health challenges and a lack of formal skills. Currently, low-skilled jobs are decreasing, making matters even harder for those without necessary education or other qualifications. Greenland stands out in this regard. Though increasing, the education level in Greenland remains the lowest in the Nordic region. About half of the population aged 25–64 have education above the lower-secondary level. Although there is a tendency towards more jobs requiring higher skills, there are still many unskilled jobs as well as part-time jobs without fixed hours. In 2021, 21% of the adult population were outside the labour market (Høgedahl & Ravn, 2021). In Sweden there has been a rise in long-term unemployment (Mångs & Edholm, 2022). The country is currently experiencing a recession, with an increase in the number of redundancies and bankruptcies, and unemployment is believed to go on rising in 2023 and 2024 (Regeringskansliet, 2023a).

Despite an overall well-functioning labour market, the Nordic countries face challenges regarding the number of people excluded from the labour market. Norway has, for instance, the highest proportion of people on permanent and temporary health-related benefits and the highest sickness absence in the OECD (Hemmings & Prinz, 2020). All countries face substance use issues, with both alcohol and illicit drugs being a problem. The prevalence of risky alcohol consumption and illicit drug use varies, but it’s a concern in all these nations. People with substance use problems are mainly excluded from working life, and unemployment rates for individuals in treatment for a substance use disorder (SUD) are high, with estimates in the range of 81–89% in Norway (Rognli et al., 2023).

The registration of inhabitants with substance use problems varies across the Nordic region. Despite registration differences, the data still provides an overview of the current situation. In Denmark the health authorities estimate that 585,000 Danes have a risky level of alcohol consumption, 140,000 Danes are addicted to alcohol, and 52,000 Danes have highly problematic use of drugs (Indenrigs- og Sundhedsministeriet, n.d.). In Finland, alcohol consumption has decreased over the past ten years, whereas the use of drugs has increased. However, according to the 2016 Drinking Habits Survey, the risk threshold of the AUDIT test score screening for alcohol use disorders was exceeded by 21% of women and 31% of men (Warpenius, 2021). Use of alcohol and cannabis are considered the most important public health problem in Greenland, even if alcohol consumption has decreased and is on a par today with the other Nordic countries (Statistics Greenland, 2021). According to the Icelandic Directorate of Health, 24% of the adult population had a risky alcohol consumption in 2022 (Embætti landlæknis, n.d.). In Norway, at least 200,000 Norwegians have a risky alcohol consumption, 20,000 have illicit drug issues, and 30,000 have problematic use of prescription drugs (Folkehelseinstituttet, 2022). According to the Public Health Agency, approximately 1.3 million Swedes, out of a total population of about 10.5 million, have a risky alcohol consumption level, and 310,500 are dependent (Folkhälsomyndigheten, 2022). A study from 2017 estimated that 680,000 individuals used drugs, whereof 415,000 had used drugs that were not prescribed by a doctor (Sundin et al., 2018).

A variety of methodological approaches has been employed in crafting the country profiles. Each of the countries has carried out varying degrees of systematic literature searches, covering both domestic and global databases such as PubMed. In fact, this report does not represent any systematic review of the field. Hence, the descriptions of the interventions are not an exhaustive list of interventions currently employed for individuals with substance use problems. Furthermore, pertinent legal statutes and regulations have been extracted through searches of national juridical databases. The authors have also drawn upon their individual expertise, whether as researchers (as seen in the case of Denmark) within these specialised domains, or as practitioners (as observed in Iceland). Additionally, select country profiles have been partially informed by interviews conducted with key informants in relevant positions. Moreover, the Norwegian team has enlisted a reference group to provide comments and feedback on specific sections of the report.

A case-oriented comparative approach facilitates the analysis and has been employed in a select number of cases. Each country profile represents a case. This approach allows us to gain a nuanced understanding of particular phenomena, patterns, and relationships (della Porta, 2008). The objective was to discern both commonalities and distinctions among the countries, revealing the core themes, mechanisms, and factors that shape the labour market integration of individuals with substance use problems. Additionally, efforts were made to identify successful interventions and organisational settings for service delivery pertaining to the labour market integration of the target group.

The remainder of the report is structured in two overall parts. Part one covers six chapters with country profiles from Denmark, Finland, Greenland, Iceland, Norway, and Sweden written by researchers and experts representing the different Nordic countries. Part two, the final chapter, presents the results of the case-orientated comparative analysis based on the country profiles. This includes a table summarising the types of interventions and their reported effects on people with substance use problems in the Nordic countries.