Sweden

Sweden has robust policies to address alcohol and drug use and reduce their negative impact on individuals and society (Regeringen, 2022). Even though the two policy fields share common ground, they have taken different approaches to achieve this overarching goal: alcohol policies emphasise prevention and treatment of alcohol-related problems in a harm-reduction framework, while drug policies seek to achieve a drug-free society, a vision zero so to say. Harm reduction measures are in place to limit the negative consequences associated with drug use, such as social exclusion. Opiate maintenance treatment (OMT) is an example of these measures aimed at helping individuals achieve employment, self-sufficiency, and economic stability (Socialstyrelsen, 2020). 

It is worth noting that not all individuals who have substance use problems are automatically excluded from the workforce. Alcohol and drug dependence are classified as medical conditions, which means that individuals with these conditions are entitled to enhanced employment protection and rehabilitation support. According to 7§ in the Employment Protection Act (Lag om anställningsskydd, 1982), there must be valid reasons for terminating an employee’s contract, and substance use problems are not sufficient grounds alone. Employers are required to offer assistance to employees struggling with substance use problems, and only if the employee refuses help or if the employer’s efforts fail despite reasonable attempts, can dismissal be considered. 

Some individuals who struggle with substance use problems have not been a part of the labour force for a long time or have never been employed due to their problems. These individuals may or may not have undergone substance use treatment. The main objective of these treatment programmes is to help individuals overcome their dependence and achieve a healthy and stable life. Employment and other meaningful activities are recognised as crucial components of the recovery (Walton & Hall, 2016). Therefore, the system aims to support individuals in finding and maintaining employment as part of their overall treatment plan. The national guidelines for care and support for substance use and dependence include various interventions that can promote employment, such as innovative training models and individually tailored support for work (Socialstyrelsen, 2019).  

Also, the Social Services Act (Socialtjänstlagen [SoL], 2001) stipulates that dependent individuals receive the care and help needed to recover (SoL ch. 5 §9, 2001). The Social Welfare Board shall promote the individuals’ right to work (SoL ch. 3 §2, 2001) and support them in getting a meaningful employment setting (SoL ch. 5 §7, 2001). 

The Ministry of Labour is responsible for matters relating to the labour market, labour law, and the work environment at a national level. The overarching labour market policy aims to ensure that all people who can have the opportunity to participate in working life, with a commitment to full employment. If individuals are not fully employed, a number of measures can be taken, including economic support from the Social Insurance Agency. Social insurance benefits cover a broad spectrum and are regulated in the Social Insurance Code (Socialförsäkringsbalk, 2010). However, the compensation for active job seekers or those participating in an activity at the Employment Service is quite low and does not make up for a usual salary.

Disability pension is a compensation of a set duration specifically targeted at young individuals aged 19–30. Its primary objective is to offer activities that can enhance functional abilities and improve work capacity while offering financial security. However, evidence suggests that these activities do not adequately facilitate young adults’ integration into the labour market. Instead, a majority of recipients end up transitioning to permanent sickness compensation (Olsson et al., 2017).

The national strategy for addressing alcohol, drug, doping, and tobacco (ANDT) use aims to reduce the harm caused by substance use. Substance use treatment encompasses a wide range of measures to meet the diverse needs of individuals, including different types of treatment and social support initiatives such as housing and employment support. Collaboration between different organisations, such as social services, the Social Insurance Agency, and the Employment Agency is crucial for effective support. However, the government has recognised the need for further clarification on which efforts need to be developed and implemented, and who is responsible for them (Socialutskottet, 2021). 

In a recent review of the ANDT strategy, the National Board of Health and Welfare (Socialstyrelsen, 2023) highlighted the lack of data on the specific needs and types of care and support provided to individuals with substance use problems, making evaluation difficult.

The Swedish Public Employment Service has a long history and was originally established as a state authority. In 2019, a reform of the Employment Service began, and at the end of 2022, it was completed with privatising the job centres. The Employment Service still performs some services under own authority but primarily collaborates with independent suppliers who manage the matching between individuals and the labour market or relevant education on behalf of the Employment Service. Previous studies have investigated if the unemployed person’s chances of finding a job are affected by whether the provider is a public or private employment agency. Results show no evidence that private contractors are better, and they are often more expensive than public ones (Arbetsmarknadsutredningen, 2019). Ongoing development work aims to improve the authority’s control and follow-up work with suppliers. The Employment Service must analyse which support is best provided in collaboration with other relevant actors, such as municipalities or idea-driven actors (Analysavdelingen, 2023).

Studies have demonstrated that assistance and support from employment agencies are crucial for individuals to find work, along with subsidised employment and training programmes. It often takes a combination of initiatives to eventually secure a job (Berg, 2022). Additionally, work-oriented rehabilitation necessitates the involvement of several actors to adhere to national guidelines. Therefore, the Employment Service collaborates closely with state authorities such as the Swedish Social Insurance Agency (Försäkringskassan, 2022). The Employment Service operates according to the same regional division used by other administrative bodies and is represented in various municipalities.

It is important to note that although employment agencies and subsidised employment can be useful in finding work, they may not be enough for individuals with substance use problems. These individuals may require more specialised support, such as counselling, substance use treatment, and vocational training that addresses the unique challenges they face in the labour market. The national ANDT strategy (Regeringen, 2022) against the use of alcohol, drugs, doping, and tobacco requires a multi-sectoral approach involving state authorities, municipalities, regions, businesses, civil society organisations, and various other actors. The Ministry of Social Affairs has a coordinating responsibility for the government’s ANDT policies, while cross-sectoral coordination is the remit of the Public Health Agency. Other state authorities such as the National Board of Health and Welfare, the National Agency for Education, the Swedish Police, and the Prison and Probation Service are also involved. The County Administrative Boards are tasked with coordinating the preventive ANDT work on a regional level, while municipalities and regions play a vital role in developing and implementing policies. Civil society organisations, including children’s and youth organisations, patient, user, and family organisations, also contribute to the prevention of ANDT.

Collaboration within and between local, regional, national, and international levels is considered a necessary condition for the effectiveness of ANDT strategies (Folkhälsomyndigheten, 2020), along with substantial support and dedication from non-profit organisations (Folkhälsomyndigheten, 2023). Nevertheless, current reports primarily concentrate on the concept of collaboration itself (e.g., Folkhälsomyndigheten, 2023), rather than providing evaluations of its actual implementation and outcomes.

Substance use treatment is available within both the regional healthcare system and the social services, managed by the municipalities. Healthcare can help with medical treatment. For example, opioid maintenance treatment (OMT) is organised within the regional healthcare system (Hälso- och sjukvårdslag [HSL] ch. 8, 2017), with certain exceptions where the municipality is in charge (HSL ch. 12 §§1–2, 2017). While there are also private caregivers, the region or municipality is still responsible for the care given. Social services can help with, for example, financial and employment support. The national guidelines issued by the National Board of Health and Welfare (Socialstyrelsen, 2019) emphasise the importance of collaboration between healthcare and social services. Also, regions and municipalities have an obligation to enter into joint agreements on cooperation regarding individuals with alcohol or drug use problems (SoL ch. 5 §9, 2001; HSL ch. 16 §3,2017). 

The overarching labour market policy aims to provide opportunities for all individuals who are able to work and participate in the labour market, while also facilitating adjustment in the labour market and promoting job security. This policy area includes initiatives to support young people in finding employment, matching job seekers with available positions, labour market programmes, unemployment insurance, and access to the European Social Fund (Regeringskansliet, 2023b). Even if many companies struggle with a shortage of labour, there are still large numbers of jobseekers in the market. To combat long-term unemployment and address the skills gaps, the Employment Service offers a variety of programmes and support arrangements.

The national guidelines for care and support in cases of substance use and dependence (Socialstyrelsen, 2019) recommend efforts to promote employment for individuals with substance use problems. However, in labour market programmes, individuals with such problems are not a separate category but are instead included under the broader category of the disabled, which encompasses individuals with reduced work capacity, illnesses, diagnoses, or other difficulties.

The process of returning to work often involves a lengthy period of pre-rehabilitation, skills training, and assessment of work ability. The job search itself is often delayed until later in the process (Areberg, 2013). For example, individuals who have not completed upper secondary education have limited employability in today’s labour market. Therefore, the Employment Service is increasingly matching unemployed indivi­duals with education that leads to employment. This work rehabilitation model is known as train-then-place and is used by organisations such as the Social Insurance Agency and the Employment Service (Areberg, 2013). As part of this model, the Employment Service provides support for primary and upper secondary level studies, as well as university studies, and sometimes offers financial assistance and intro­ductory courses to help individuals complete their studies (Arbetsförmedlingen, 2023a).

The Community Reinforcement Approach (CRA) model combines psychosocial treatment with psychosocial support interventions, aiming to enhance employability by imparting practical skills and knowledge, and recommending a gradual intro­duction to the job market. The CRA model is administered by a support person with specific training in the method (work specialist or job coach), usually employed within the psychiatric sector, and it targets individuals with problematic substance use (Vård och insats, 2017). However, although recommended and in use, the method has not been systematically reviewed nor has it been investigated in any primary study (Statens beredning för medicinsk och social utvärdering, 2019).

The concept is not to alter individuals through extensive job training and gradual transition, but rather to identify a job that makes the most of their motivation and interests. Work-based learning is believed to provide the participants with funda­mental knowledge and understanding of the requirements of the working world in a relaxed and secure work atmosphere (Arbetsförmedlingen, 2023b). If an individual requires assistance or support in transitioning into or re-entering the workforce, there are various types of supported employment available, including new start jobs, wage subsidies, and introductory jobs. These initiatives, along with work experience place­ments, are believed to be beneficial for individuals with a reduced work capacity or for those who have been unemployed for an extended period (Arbets­förmedlingen, 2023c). The extensive provision of subsidies has resulted in a system that is challenging to comprehend, and the empirical knowledge regarding how the design of various subsidy systems impacts their outcomes is incomplete and fragmented (Forslund, 2018).

The place-then-train methodology is exemplified by the application of individual placement and support (IPS) (see Fact box 1). The National Board of Health and Welfare (Socialstyrelsen, 2019) concludes that it is a more effective method to get a job than is traditional work rehabilitation. However, even though IPS is recommended for individuals with substance use problems, it is not currently in use for this target group (Samordningsförbundet Stockholms stad, n.d.). Hence, the work rehabilitation model for individuals with substance use problems that increases the possibility of getting and keeping a job is not utilised (Centrum för evidensbaserade psykosociala insatser [CEPI], 2022). 

Individuals seeking help are expected to choose and contact one of the private suppliers contracted by the Employment Service, and work together to determine the best way to find a job or begin an education. The prescribed period for participation is six months, after which the outcome is assessed. If necessary, this period can be prolonged for an additional six months.     

A review of the media uncovered that approximately half of the participants start all over again (Frisk & Lund, 2021). Also, it has been recognised that the private suppliers prioritise resourceful jobseekers, while those requiring more assistance are left idle (Berge & Habibija, 2022).

A report published by the Institute for Evaluation of the Labour Market and Education Policy IFAU (Bennmarker et al.,2021) asserts that the compensation system in Prepare and Match operates on a performance-based model: it aims to reward suppliers for promptly placing participants into jobs or training. The participants are categorised into three distinct levels based on their assessed proximity to the labour market, and the compensation provided to the suppliers varies accordingly. This implies that higher compensation is offered to job seekers who are further away from the labour market, thereby providing incentives to engage with all participants. However, the report discovered that the compensation varied more across the different levels than did the participants’ employment prospects.

The Employment Service has identified a lack of educational opportunities, long-term study financing options, and low study motivation among its target group. A survey conducted by the authority indicates that many of the individuals assigned to apply for regular education do not know how to complete the application and start their studies. As a result, the Employment Service believes that its efforts to guide jobseekers on how to apply for regular education have not yielded the desired outcomes thus far (Arbetsförmedlingen, 2022).

There is a strong association between the use, harmful use, and dependence on ANDT substances and other health problems, particularly mental illness (Socialutskottet, 2021). The National Board of Health and Welfare (Socialstyrelsen, 2019) recommends that healthcare and social services provide integrated treatment to individuals with alcohol and drug problems and severe mental illness. This treatment should include psychological and psychosocial interventions such as the Community Reinforcement Approach mentioned earlier. 

It has been demonstrated that many opioid maintenance treatment (OMT) clients also experience psychiatric comorbidity (Löfvendahl & Carlsson, 2020). One of the goals of OMT is to enhance employment opportunities, self-sufficiency, and financial stability (Socialstyrelsen, 2015). However, a qualitative study of OMT participants revealed that most patients desire more assistance with employment and better collaboration with other actors (Richert & Johnson, 2020).

Whilst most interventions in Sweden stem from the state or the regions, and are performed by private actors, non-profit organisations also play an important role. For example, Skyddsvärnet provides job training, as well as references and networks (Skyddsvärnet, 2021). Stadsmissionen (City Mission) offers job training within their own businesses and has recently been approved as a supplier for the Employment Service programme Prepare and Match (Stockholms Stadsmission, n.d.). The Salvation Army (Frälsningsarmén) and The way out (Vägen ut) have a pronounced Christian basis and provide job training (Frälsningsarmén, n.d.; Vägen ut., n.d.).

Generally, individuals with substance use problems do not receive specific attention regarding the labour market, despite the emphasis on employment in national guidelines by the National Board of Health and Welfare and the ANDT strategy. There is a clear emphasis on the need for collaboration among various parties, recognising the individuals’ often complex life situations and the requirement for care, support, and treatment from multiple authorities and businesses simultaneously. While discussions on labour market programmes are common, there is a lack of evaluations of their effectiveness.

Overall, the well-intentioned approach of involving multiple actors and offering a wide range of labour market programmes tends to prioritise these aspects rather than the individuals themselves. While the individuals’ perspective is considered, such as their right to choose a private supplier, they are also grouped into broad categories such as the disabled. It is not easy to navigate within this complex system, which may result in giving up. Also, we do not know whether this system is effective for individuals with substance use problems.