Background: Increasing Ethnic and Cultural Diversity in Sweden

1. Association Between Immigrant Status and History of Compulsory Drug Treatment in a National Sample of Individuals Assessed for Drug Use Disorders Through the Swedish Public Welfare SystemLena Lundgren, Jan Brännström, Bengt-Åke Armelius, Deborah Chassler, Stefan Moren and Sarah TrocchioPublished in: Substance Use & Misuse, 47:67–77, 2012Presentation Prepared by Sarah Trocchio, MSW & Ivy Krull, MSW, MPH

2. Background: Increasing Ethnic and Cultural Diversity in Sweden

3. Background: Compulsory Drug Treatment in Sweden • The compulsory treatment law (LVM) is civil in nature and does not include a punitive component . • Steps to enter compulsory treatment: • Individual brought into Immediate custody (danger to themselves or others due to substance abuse) • Assessment of need by social welfare agency-social worker • Mandated to enter treatment if agency determines need • Nearly 80 % of individuals brought into custody were mandated to go into treatment in 2008 (Gerdner & Berglund, 2011) • Average length of treatment = 141 days (Gerdner & Berglund, 2011)

4. Background: studies on Compulsory Treatment Users Compared to Voluntary Treatment Users

5. Background: Drug Use and Treatment Disparities Research in the U.S. • U.S. Research Findings: • Immigrants and refugees utilize drug use disorder services less than native-born populations (McLean-Leow, Goldstein,& McGlinchy, 2006). • Racial and ethnic minorities experience more difficulties in obtaining the most appropriate treatment services, are more vulnerable to gaps in service, and may encounter bias in treatment assignments (National Institute on Drug Abuse, 2003). • Use of compulsory treatment can be understood as ineffective use (or non-use) of voluntary treatment • Using a health disparities lens:

6. Research Question: • Exploratory, cross-sectional study

7. Methods: database • In Sweden, nearly half of all counties use the ASI (McLellan et al., 1992) to collect baseline data on individuals with drug use disorders • This data is entered into a national database, which includes data spanning from 2002- present • In 2009, Armelius et al (2009) used the Swedish ASI data to create a nationally representative, individual level database for research purposes

8. Methods: Sample Description • Study sample was 13,309 adults in the Swedish welfare system who had been assessed for a drug use disorder (Lundgren et al., 2012) • 69.1 % were males, 69.0 % were native born Swedes, and the mean age was 40.1 years (Lundgren et al, 2012 ) • A substantial number of the sample had a history of mental health treatment • Nearly half (44 %) had a history of outpatient psychiatric treatment • Almost a quarter (23 %) had been in inpatient psychiatric treatment • 15 % reported a history of compulsory treatment for narcotics

9. Methods: IndependentVariables • Demographic Characteristics (age, gender, education) • Psychiatric Treatment History • Criminal Justice Status • Housing Status • Immigrant status(one five category variable): • Individual and their parents born in Sweden • Individual born in either Norway, Denmark, or Finland • Individual born outside of Sweden, Norway, Denmark, and Finland • Individual born in Sweden and at least one parent born in Norway, Denmark, or Finland • Individual born in Sweden and at least one parent born outside Sweden, Norway, Denmark, and Finland

10. Methods: Dependent Variable

11. Data analysis • Bivariate statistical analyses • Binomial logistic regression methods where all variables significant at the bi-variate level were entered as a single block.

12. Results: Bivariate Analyses

13. Results: Multivariate Analyses

14. Multivariate Results: Significant results • Respondents with higher levels of education were 12 % less likely to report a CT history • Those with a history of inpatient psychiatric mental health treatment were 57 % more likely to report a CT history • Individuals with a history of criminal drug charges were 12 % more likely to report a CT history • Respondents on parole or probation were 70 % more likely to report a CT history • Those that were homeless were 88 % more likely to report a CT history • Individuals who had ever received medication for psychiatric problems were 64 % less likely to report a CT history

15. Multivariate Results: Immigrant Status and Compulsory Treatment • No significant association between first generation immigrant status and likelihood of reporting a history of compulsory drug treatment for narcotics • Non- Nordic second generation immigrants were 41 % more likely than Swedes with Swedish parents to report having a history of compulsory treatment for druguse after controlling for age, gender, education, history of inpatient and outpatient mental health treatment, history of receiving medications for psychiatric problems, number of times charged with a drug related crime, homeless status, and being on parole

16. Discussion: • Since treatment is provided free of charge, lack of ability to pay does not explain disparate rates of compulsory drug treatment use • Acculturation and Assimilation studies may provide one explanatory lens for these discrepancies; • Acculturation research has found that substance abuse increases as acculturation increases(Gil, Wagner & Vega, 2000; Hahm,Lahiff, & Gutterman,2003, 2004; Ortega,Rosenheck, Alegria, & Desai, 2000) • Also, some studies suggest that some second generation immigrant groups are more likely to assimilate into structurally disadvantaged groups. (Portes and Zhou, 1993; Portes and Rambaut, 2005)

17. Additional theories; • Stigma: • Cultural stigma may prevent certain ethnic/cultural groups from seeking help for their drug use disorders voluntarily (Bhattacharya, 2002; Abe-Kim et al., 2006; Le Myer, Zane, Cho & Takeuchi, 2009) • Unintentional Discrimination: • Vyn Ryn and Fu (2003) found that providers’ stereotypes about help seekers influence practice decisions • Providers’ view of help seekers therefore can lead to discrimination and perpetuate health disparities (Vyn Ryn & Fu, 2003)

18. Policy and Practice Implications • Culturally competent and specific outreach and drug disorder treatment should be promoted through Sweden • Practitioners who complete ASI assessments for drug use disorders should be trained in conducting assessments with culturally diverse populations • More research is needed exploring the role of acculturation, stigma and discrimination on patterns of addiction treatment use.

19. Limitations

20. References • Armelius, B-Å. & Armelius, K. (2011). En naturalistisk studie av 14000 svenska missbruksklienter baserad på Addiction Severity Index, ASI. In Missbruket, Kunskapen, Vården. Missbruksutredningens forskningsbilaga. SOU 2011:6, Chapter 6, • Armelius, B-Å., Nyström, S., Engström C. & Brännström, J. (2009) Referensmaterial för bättre använding av ASI intervjun. The Institute for the development of methodology in social work. Socialstyrelsen (National Board of Health and Welfare). Stockholm Sweden. • Gerdner, A (2004). LVM-vårdens genomförande, utfall och effekt - En kontrollerad registerstudie i Jämtland. I: Forskningsrapporter, Bilagedel till LVM-utredningens betänkande "Tvång och förändring", SOU 2004:3, Socialdepartementet, s. 415-476. • Gerdner, A. & Berglund, M. (2011). Tvångsvård vid missbruk – effekt och kvalitet. In: Missbruket, kunskapen, vården. Missbruksutredningens forskningsbilaga SOU 2011:6, s. 653-770. • Gil, A. G., Wagner, E. F. & Vega, W. A. (2000). Acculturation, familism and alcohol use among Latino adolescent males: Longitudinal relations. Journal of Community Psychology ,28(4), 443-458. • Hahm, H. C., Lahiff, M., & Guterman, N. (2004). Asian American adolescents’ acculturation, binge drinking, and alcohol and tobacco using peers. Journal of Community Psychology, 32(3), 295-308. • Hahm, H. C, Lahiff, M., & Guterman, N. B. (2003). Acculturation and parental attachment in Asian American adolescents’ alcohol use. Journal of Adolescent Health, 33, 119-129. • McLellan, A.T., Kushner H., Metzger, D., Peters, R., Smith, I., Grissom, G., Pettinati, H., & Argeriou, M. (1992). The fifth edition of the Addiction Severity Index. Journal of Substance Abuse Treatment, 9, 199-213.

21. References: Continued • McLean Leow, D., Goldstein, M. & McGlinchy, L. (2006). A selective literature review: Immigration, acculturation & substance abuse. Newton, MA: Education Development Center, Inc. • National Institute on Drug Abuse (NIDA) (2003). Drug use among racial/ethnic minorities. Rockville: Maryland. • Ortega, A. N., Rosenheck, R., Alegria, M., & Desai, R. A. (2000). Acculturation and the lifetime risk of psychiatric and substance use disorders among Hispanics. Journal of Nervous and Mental Disease, 188, 728–735. • Portes, A., & Zhou, M. (1993). The new second generation: Segmented assimilation and its variants. Annals of the American Academy of Political and Social Science, 530, 74-96. • Portes, A., & Rambaut, R.G. (2005). Introduction: The second generation and children of immigrants longitudinal study. Ethnic and Racial Studies, 28 (6), 983-989. • Statistics Sweden, (2010) Born in Sweden – but still different? The significance of parents’ country of birth. Statistiska Centralbyrån, Stockholm, Sweden. • Storbjörk, J. (2010). Vem tvångsvårdas? Utmärkande drag för tvångsvårdade respektive frivilligt vårdade personer med alkohol- och narkotikaproblem. Nordic Studies on Alcohol and Drugs, 27(1), 19-46. • U.S. Department of Health and Human Services. (2004). National Institute on Drug Abuse: Drug use among racial/ethnic minorities. Retrieved from http://archives.drugabuse.gov/pdf/minorities03.pdf • Van Ryn, M. & Fu, S.S. (2003). Paved with good intentions: Do public health and human service providers contribute to racial/ethnic disparities in health? American Journal of Public Health, 93(2), 248-255.

22. QUESTIONS? COMMENTS? Dr. Lena Lundgren Boston University School of Social Work llundgre@bu.edu