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The Swedish Drug Problem: Conceptual understanding and Problem Handling, 1839-2011

Aim To analyse the Swedish drug question by examining dominant concepts used to portray the problem in the years 1839-2011. Theoretically, we understand these concepts as ideological tools that shape the political initiatives and administrative efforts to deal with the problem. The study is based on two kinds of source material: articles in medical journals from the years 1839-1964 and public reports on vagrancy, the alcohol problem, mental health and the drug problem from the years 1882-2011. Findings During the nineteenth century and the first part of the twentieth century the drug problem remained an individual problem handled by doctors. When the Swedish drug problem was established as a political question from the 1960s on, it also came to disengage itself from the medical frame of understanding. Medically oriented descriptions of “dependence” and “addiction” have appeared adequate or attractive when, for example, the socially motivated coercive treatment solution has been discredited (as in the 1970s), when there has been a desire to connect with an internationally accepted terminology (as in the 1990s) or when a new organisational model with a stronger professional support has been on the agenda (as in the 2010s). But otherwise the social problem description has called for concepts that have more or less explicitly dissociated themselves from speculations in physiological or psychological predispositions for substance abuse.


Introduction
The aim of this article is to analyse the Swedish drug question by examining dominant concepts used to portray the problem in the years 1839-2011. During the 1800s, drugs never qualified as a social problem in a broader sense and in the 1887 edition of a famous Swedish encyclopaedia (Nordisk familjebok, 1887, p. 810), the word "narcotics" is described as referring to "depressant substances" in a presentation with a medical and pharmacological approach. Drug abuse was not discussed at all, because this was a little-noticed phenomenon outside of the medical domain.
Our search for the naming and problem formulation of the drug issue therefore begins by reading the medical specialist press. By the turn of the nineteenth and twentieth century, social problems were being debated with a totally new intensity.
The dominant problem description -the social question -can partly be described as a uniform problem, partly as a problem with many faces. It was about poverty, the individual's but also the newly awakened industrialised nation's relative poverty.
The decades before and after the turn of the century were characterised by industrialisation, modernisation, urbanisation and widespread concern about the population's qualities and ability to live up to the new demands of the future. Emigration, fear of degeneration, drunkenness and prostitution were highlighted as selected parts of a social problem complex that in earlier research has been termed the labour question, the poverty question or the alcohol question (Edman, 2004). This potentially opens up for a description of drugs in a broader context: as part of, for example, the problem of vagrancy, alcohol or mental health.
Theoretically, we understand the investigated concepts as ideological tools that structure political initiatives and administrative efforts to deal with the drug problem. The ambition has not been to nail down the conceptual definitions to any particular ideology, but rather to show how the work of concepts has been politically driven -i.e. based on political ambitions to achieve some reforms rather than on how best to describe a certain phenomenon. As historian Willibald Steinmetz (2002) has formulated it: what can be said (das Sagbare) structures what can be done (das Machbare). Every attempt to settle a normative vocabulary can therefore be regarded as an ideological action (Skinner, 1999). As has been shown in alcohol and drug history studies (e.g. White, 2004;Edman & Stenius, 2014), this also means that comprehensive changes in the field can be derived from the analyses of used concepts.
Our study is based on two kinds of source material: articles in medical journals from the years 1839-1964 and public reports on vagrancy, the alcohol problem, mental health and the drug problem from the years 1882-2011. 1 The medical journals cover a period when the drug issue was not discussed in the public material, and a more extensive analysis of this material has previously been conducted by Börje Olsson (1994). The use of public reports has proven fruitful especially since the recognition of drug consumption as a public problem from the late 1960s on. Previous studies of some of this material have been conducted for the period up until 1982 (Edman, 2012;Edman & Stenius, 2014).
The empirical investigation has been chronologically structured. After analysing the long period between 1839 and 1964, when the drug problem was mainly a marginal issue for the medical profession, we turn our focus to different conceptual framings of the drug problem from the mid-1960s up until today. The article concludes with a summarising discussion.
The medical privilege to define the problem  applies to both the epidemiological development of drug use and abuse as well as to the ensuing drug policy. In order to understand the dominant concepts that make up the "modern" drug question, it is absolutely critical to have some basic knowledge of the historical picture. This is especially true when attempts are made to compare the Swedish drug policy with the situation in other countries. In the following section, the history before the modern Swedish drug problem will therefore be analysed in terms of descriptions of perceived problems, prescribed solutions and dominant concepts used to define its different aspects. The analysis will cover the time period from 1839 to 1964. During this time, drug problems were almost exclusively dealt with within the medical field. In this article we highlight only a few illustrative examples of this. The analysis focuses specifically on how drug use, abuse and problems have been discussed and defined in medical journals. The studied articles are essentially representative of how the issues were discussed in Swedish medicine during this period (Olsson, 1994), and with few exceptions the medical discourse on drugs was tantamount to how the issue was discussed in the wider community.

The medical problem description before the Second World War
During the period from the mid-1800s until about 1900 drug abuse was problematised rarely and mostly indirectly. The articles mention or talk about abuse in three ways: 1) as temporary abuse leading to severe poisoning; 2) as abuse of easily accessible and often over-the-counter combination drugs containing narcotic substances, and; 3) as abuse that had started as legitimate medical use of drugs. The articles treat the first and second category in a neutral way in stating that some people either use drugs more than the doctor has prescribed or entirely outside the legitimate medical system. In both cases the term abuse [missbruk] refers to these non-acceptable ways of using drugs. It was indeed risky to use them incorrectly, and in these cases such use constituted the very meaning of the term abuse. Even if it was not openly claimed, it was lack of character that made some persons disobey the doctor's prescription, and consequently give in to pleasure.
[…] the cause of the disease is mainly, and often only, nourished by a weak and deteriorated willpower. Even if the willpower has been strong and dynamic before the beginning of morphine use, sooner or later anaesthesia occurs which will affect both morality and physical capacity (Wetterstrand, 1896, p. 369).
No actual descriptions were made about what abuse really was, other than it was simply said to be a disease. Empirical data suggests that drug abuse was phrased as a problem only in the sense that excessive use was not good, rather like saying that it was not good to use too much of any risky product. It would lead to a gradual destruction of mental and physical health, while problem descriptions of a social, economic or criminal nature were missing altogether. These views on the causes and problems related to drug abuse explain why the solutions to the perceived problems were placed within the medical system. Detoxification and treatment were seen as the main components in solving the problems, supplemented with an administrative sharpening of how the substances were supplied from pharmacies.
All in all, drug abuse was seen as a medical and individual problem. Still, "abuse" referred to such use as did not conform to medically prescribed ways, pertaining in practice to both temporary and more regular drug use. In the discussion about potential drug problems, however, it is clear that the focus was on the frequent and habitual use of drugs, usually in high doses.
The most obvious change in relation to the concept of abuse was the actual link to the users/abusers. "Abuse" was constructed from an empirical and clinically driven approach that was common in contemporary medical practice as patients were observed and treated. Yet there were no deeper insights in psychiatry, brain research was not especially developed, and research of social processes was rudimentary, which excluded elaborated definitions related to these areas. On the other hand, drug users have always been before the Unauthenticated Download Date | 12/16/16 12:18 PM eyes of the doctors, and in the absence of other information immediate impressions of them created the concept. What we saw in the early twentieth century was partly a growing group of people with serious mental problems using/abusing drugs, not least because barbiturates were prescribed for such diseases; and amphetamine abuse that was socially and culturally conditioned rather than medically induced. Two different perceptions of abuse grew out of these different sources of information. The first, which was also the clearest and most widely used in the medical literature, generated a definition based on disease concepts. The other linked abuse to the users' social status. This became more common towards the end of the period as amphetamine use increased. It must be stressed that there were no real discussions about the concept of abuse in the medical journals, neither in the nineteenth century nor during the first part of the twentieth century.
In other words, one has to be careful not to draw too firm conclusions in those cases where terms such as substance abuse or dependency were used.
Abuse was conceptualised as a disease without further reflection or discussion, and we can distinguish two ways of using the disease concept. First, some form of disease existed already before abuse arose. In these cases abuse developed either through a process where narcotic substances were used as part of the treatment, or through a primary disease which in one way or another caused abuse. In the former, emphasis was put on the pharmacological substance while the latter focused on the sick individual. The following statements are typical of the period and illuminate the latter conception: Inclination for abuse of the medicine occurs only in patients with psychopathic traits [...] (Alfvén, 1940(Alfvén, , p. 1032).
[…] most of these patients who have a more or less pronounced tendency to develop drug abuse are neuro-psychopaths (Lindner, 1939(Lindner, , p. 2292.
The conceptualisation of long-term, regular abuse of drugs in high doses as a disease was linked to the pathological conditions that followed upon such behaviours. The persons/patients were thus considered to be sick. Typical psychological consequences of more prolonged abuse could be: […] insomnia, hypersensitivity, neuralgia, anxiety, depression and excitation (Jäderholm, 1878, p. 672).  (Santesson, 1926, pp. 889 f.).
This quotation relates to heroin and cocaine. Abuse of these drugs was a relative-Unauthenticated Download Date | 12/16/16 12:18 PM ly new phenomenon in the early twentieth century and played only a minor role in how drug problems were perceived and defined. Despite efforts to investigate the cocaine situation in Sweden, only a few cases of cocaine abuse were detected (Riks arkivet, 1933). The requirements for a tightening of the drug laws that were articulated at the time were never realised, and an analysis of the situation in the 1920s shows that the medical definitions of the drug problem were not significantly affected (Lindgren, 1993;Olsson, 1994).
However, something that soon would come to play a crucial role in the formulation of the Swedish drug problem was the introduction of amphetamines in the late 1930s. Initially, the disease concept, as developed within the medical system, was transferred also onto amphetamine use. However, as time passed, the incongruence became ever clearer between the traditional approach and the images that slowly began to emerge around the use of amphetamines. This caused the medical profession to gradually withdraw from the drug issue towards the mid-1960s. This was also instrumental in how drug abuse was conceptualised differently in Sweden compared to most other countries.
This increased to over 300,000 users in 1959 (Olsson, 1994). Growing awareness of the risks of central nervous system stimu-

The drug problem as a public problem
Since the drug problem was not formulated as a political or a public problem before the 1960s, we find only casual remarks on the drug problem in the public reports from the late nineteenth century and early twentieth century (Edman, 2012). 192) One important conclusion was that drugs certainly could be more damaging to the individual than alcohol, but that drug use hardly led to the social harm that the law was aimed against.
The issue of the compulsory treatment laws' applicability to drug consumers was raised again in an investigation in 1929.
A sustainable description of narcotics emerged: these were substances that promoted "habituation" and increased "tolerance" -and even a moderate dose of morphine would make the user "a helpless slave to the need" (SOU 1929:29, p. 122).
The requirement for dose escalation was a part of the problem scenario and was therefore also socially expressed: No desire is as demoralising as this [narkotikamissbruk]. Narcomania consisted partly of "toxicomania" ("abuse of toxic substances") and partly of "eufomania" -"substances with a mood-boosting (euphoric) effect" (SOU 1964:40, p. 126).
But the salient feature of narcomania was that it would lead to "addiction". Addic The Committee dissociated itself from a terminology that had not been widely approved. This became particularly clear in the Committee's final report (SOU 1969:53) in which a number of researchers published their studies of different aspects of the drug problem. Here, the terminology appeared to be free and inquiring. One study spoke simply of "drug consumption" with no descriptions of psychological or physical dependence (Herulf, 1969, p. 13). Another study used "drug use" and "drug users" without any further attempt to define the concepts, whereas a third discussed "drug abuse" and "toxicomania" without defining the terms (Jonsson & Svedugård, 1969, p. 43;Agrell, Netz & Wolff, 1969, p. 68

Social descriptions and conceptual fumbling (1984-2000)
The reform of 1982 institutionalised the problem description and brought some conceptual stability to the field for the rest of the twentieth century. The final report from the Drug Commission in 1984 did not explicitly deal with treatment activities, causal thinking or associated conceptual clarification. Causal mechanisms were briefly discussed as an important area for research before the commission turned to addressing "drug abuse", without any medical implications (SOU 1984:13, pp. 55 & 94 f.). In 1987, the so-called Insemination Investigation delivered a report on societal measures against pregnant abusers. The report was written from a nonmedical angle and spoke of "abuse" and "overconsumption" (SOU 1987:11, p. 9).
In the same year, the Social Drafting Committee published a report (SOU 1987:22) on the compulsory treatment legislation that had by then been in effect for five years. This report mainly discussed conse- The report spoke of abuse and abusers, but at some point also about "narcomaniacs" (SOU 1994:139, p. 234). This was not any conscious attempt to shift the meaning of the studied object. Neither was the aetiology of abuse discussed in this part of the investigation. It is on the whole notable that the investigation did not have very much to say about abuse and substance abuse treatment, and when it did, it was almost exclusively about alcohol treatment. Therefore, it comes as something of a surprise when the Committee, late in the report, justified the proposed new law: In the new law, the word abuse has been replaced with the word dependence, which is an internationally recognised concept in the care of people who abuse alcohol, drugs or other dependence-producing substances (SOU 1994:139, p. 312).
That was it: no discussions on the signification of the concept of abuse, or on its applicability on high-grade consumption of alcohol or drugs, no discussions on Unauthenticated Download Date | 12/16/16 12:18 PM causation at all, just a short statement that the terminology would be aligned with "an internationally recognised concept".
However, the proposed conceptual change did not make its way into legislation (SFS 1997:313).
The Social Services Committee's conceptual shift was an attempt to provide the drug problem with a diagnosis and a psychiatric aetiology, although it was a relatively imprecise proposal. But the treatment legislation was still grounded in social considerations and the Committee had no ambition to change this. In a report by the Coercive Psychiatry Committee in 1998 one can however detect some ambivalence. Abuse was still described as a social problem; the Committee discussed "abuse problems or other social problems" (SOU 1998:32, p. 25). However, the Committee argued that not only mental disorders but also certain living conditions brought about by drug abuse could be a determining factor in assessing the need for psychiatric care. But although some abusers were treated and -according to the Coercive Psychiatry Committeeshould continue to be cared for in psychiatric care, there was no speculation on any psychiatric constitution as a ground for substance abuse. Abuse and abusers were the most common concepts; such words as narcomaniac or narcomania were conspicuously absent. "Dependence condition" occurs once as a diagnosis, and in reviews of older and other legislation there are references to "dependence on narcotic substances" and "dependence-producing substances" (SOU 1998:32, s. 123, 215 & 258). However, the Committee made no attempt to discuss the concept of dependence.
Dependence was by no means a widely spread concept during the 1990s, and the Government Grants Committee also desisted from talking about substance abuse in terms of dependence or narcomania in their report (SOU 1998:38) published in 1998. Instead, terms such as abuse, drug abuse and narcotics abuse were used. In another study (SOU 1998:140) from the same year, in which the organisation of compulsory treatment was considered, the chosen words referred to abusers and treatment of abusers. In the interim report "Drug statistics" from 1999, "abuse" and "narcotics abuse" were the most common terms, and "narcomaniac" and "narcomania" were used a couple of times without being defined. The phrase "abuse and dependence" occurred in one section, while there was speculation in another place on whether some need for treatment could be determined by means of definitions that took on "some form of dependence concepts" (SOU 1999:90, p. 19 & 85). The study did not contribute to any clarification of what was meant by this, but was considerably more helpful in explaining why this concept had come into use more frequently in the late twentieth century.
According to the report, this was a conse- Since the drug problem in most European countries has, in comparison with Sweden, a more "medical" and treatment-oriented profile, it became Unauthenticated Download Date | 12/16/16 12:18 PM natural to initially try to find a definition that linked to the dependence concept (SOU 1999:90, p. 85).
The possibility to use the criteria for dependence raised in ICD-10 was discussed but this was waived, as it would have required detailed knowledge of several aspects that could not be known. Instead, the pragmatic solution was to differentiate between problematic and unproblematic drug use.
In the first investigation (SOU 2000:38) of the drug abuse problem of the twentyfirst century, abuse was still the common term (narcomania was used at one isolated occasion). Dependence was not used at all. In "The choice -The drug political challenge", published in 2000, such terms as abuse and abuser were still the most common. But there were also references to "dependence and abuse of narcotics", "dependence on narcotics", "dependence and abuse", "dependence and abuse development", "dependence", "drug dependence", "dependence problems", and "abuse and dependence development" (SOU 2000:126, pp. 21, 108 f., 147, 151 f., 165, 167, 288 f. & 300). The word "narcomaniacs" (with inflected forms) occurred a couple of times, the word "injecting narcomaniacs" once (SOU 2000:126, pp. 76, 175, 187 f.). One can clearly detect an intensification of the use of the dependence concept as seen here; there was talk of abuse and dependence, but the difference between them was never made clear.
Neither was the role of the dependence diagnosis otherwise elucidated. Swedish substance abuse treatment was described as primarily emanating from a social perspective. The phenomenon subjected to treatment was consistently entitled abuse and there was no discussion on any specific dependence problem. Dependence did not play any part in the section on future research needs either, and the overall impression is that this internationally accepted concept was being used without being given any specific meaning.
In the public inquiry on heavy abuse which was published the year after, both abuse and dependence was used, but it was mainly abuse that described the investigated phenomenon. This investigation refrained from referring to any fixed diagnostic system and therefore came to the conclusion that there was no general agreement on what was meant by heavy drug abuse. Terms such as abusers were also avoided since this reduced the individual to her or his diagnosis. Instead, the investigation's targeted group was described as "people with heavy abuse" (SOU 2005:82, p. 32). Dutifully, the definitions of abuse and dependence in DSM-IV were outlined, without being used in the investigation.
These definitions were described as applicable to health and dependence care, not as generalised descriptions of the phenomena.
The report "A better supervision of the Unauthenticated Download Date | 12/16/16 12:18 PM abuse treatment" from 2006 was -in accordance with the title -about abuse, not dependence. On two separate occasions "narcomaniacs" were used in an unspecified way, and some references were made to "dependence-producing substances" (SOU 2006:57, pp. 21, 44, 59 & 63). Drug consumption problems were described in one place as "abuse and dependence", but otherwise the report talked about variations of abuse and abusers (SOU 2006:57, s. 114).

A medical final?
It is evident that the investigations after With reference to ICD-10, harmful use was defined as "a use of substances that can cause physical or psychological harm" (SOU 2011:35, p. 486). Dependence was defined, with reference to both diagnostic systems, as "harmful substance use leading to significant impairment or distress" (DSM) and as "a group of physiological, behavioural and cognitive phenomena in which the use of the dependence-producing substance is given a much higher priority for the individual than other behaviour, which had previously been held in such a significant position" (ICD) (SOU 2011:35, p. 486 to "more clearly mark where to draw the current limit" of mental disturbance (SOU 2011:35, p. 318). It was therefore somewhat surprising when the investigation first claimed that two-thirds of the current LVM clientele met "the criteria for one or more psychiatric diagnoses", and a few pages later made the assessment that "all those who today may be committed to LVM care will in the future be able to be

Concluding remarks
The history of problem definitions and con- The phenomenon started to be depicted as a serious threat to young people. As medi-cal perceptions and disease concepts were ill-suited to describing and understanding the process underway, the medical perceptions faded away, giving way to alternative legal and social explanatory models.
When the Swedish drug problem was established as a political question from the 1960s on, it also came to disengage itself from the medical frame of understanding that the problem had been embedded in since the mid-1800s. The compulsory treatment issue did produce a loosely defined medical terminology in the late 1960s, but at the prospect of enacting specific compulsory treatment legislation aimed at drug users in the early 1980s this problem description and terminology was abandoned.
The social description that the drug prob- When compared to other countries, coercive treatment has clearly been an important part of Swedish substance abuse treatment over the last 100 years (Lehto, 1994). Comparative studies have also shown that a social, non-medical, problem description has held a strong position in Sweden (Kaukonen & Stenius, 2005;Edman & Stenius, 2007). It is reasonable to see this as communicating certain ideas: The convincing conceptual description of drug use in future is of course hidden in the obscurity of speculation, but one thing we do know: it will give expression to a political solution that appears attractive to dominant stakeholders. These include four reports from the late 1960s when the problem was being articulated more clearly; three reports from the 1970s and early 1980s when the problem was conceptually reformulated; and 16 reports from the years 1984-2011 leading up to the contemporary conceptual handling and problem formulation of the drug issue.