The subordination of harm reduction to control in Swedish drug policy formation

INTRODUCTION: Harm reduction has gained international policy traction and increasing recognition as essential for health equity, while punitive drug control approaches have re-emerged. This study examines Sweden, known for its restrictive drug policy, to explain why harm reduction measures have gained greater acceptance alongside increasingly severe penal responses to drug offences. Furthermore, it explores the role of stakeholders in shaping these policy processes. METHODS: We analyzed three data sets 2015-2025 (media texts, key informant interviews, stakeholder comments to two commissions of inquiry) by using the Multiple Streams Framework. RESULTS: Two main problem constructions were identified: drug-related mortality and organized criminality controlling illicit drug markets. Both were related to the opening of two policy windows; however, only one led to policy change (stricter penalties), while the other did not, despite broad stakeholder support (evaluating drug use criminalization). The results highlight the role of specific stakeholders as policy entrepreneurs and indicate growing acceptance of harm reduction, although measures perceived as challenging the control-oriented track remain controversial. The results support previous findings of Sweden adopting a dual-track policy structure. However, the control-oriented policy track continues to dominate drug policy formation. CONCLUSION: This study suggests that harm reduction is likely to remain subordinate to control-oriented approaches, when the policy tracks remain institutionally separate, and when control institutions, conventions, and key stakeholders hold greater authority than human rights frameworks and may act as status quo entrepreneurs. Furthermore, focusing on control measures due to criminal networks and drug trafficking may hinder harm reduction development.