Evaluation of managers, primary care physicians and health coordinators work adapted to the National guidelines for substance abuse and addiction treatment was carried out 2012 in health centers in KalmarCounty in Sweden. The evaluation was funded by the Regional Council in KalmarCounty and implemented by LinnaeusUniversity. The evaluation aims to describe operations managers, primary care physichians and health coordinators principles and norms, using the National Guidelines for abuse and addiction treatment.

Recommendations in the National guidelines to the swedish primary health care is to meet patients with risk use of alcohol and drugs with motivational interviewing. The aim is to support patients to change their habits towards a healthier lifestyle.

Data collection consisted of questionnaires to operations managers and interviews with doctors and health coordinators, ie nurses with specialized training in the field. Questions were designed based on the guidelines witch are advisory in the field: the National Guidelines for substance abuse and addiction care (National Board of Health, 2007) and the regional guidelines (2010) for primary care, health centers in Kalmar County. The guidelines focus on the identification, counseling and treatment to patients at risk and abuse of alcohol and drugs.

The results presented will include:

1. Operations managers at KalmarCounty health centers experience that they have not received training in the National Guidelines to the extent they would need.
2. Operations managers found that patients with risk and substance abuse to a greater extent are social service responsibilities, but partly also the primary care      responsibilities.
3. Doctors and health coordinators mean that it is the responsibility of health care to detect patients with risk drinking and to help patients with hazardous drinking or drug use to find the best place for treatment and care.
4. Few managers, doctors and health coordinators knew the guidelines' recommendations for health center patients. Despite this, several health centers use procedures for the identification and treatment based on the guidelines recommendations. Some health centers offered staff training in MI, Motivational interview and used screening instruments, including alcohol consumption questions.
5. Only health coordinators routinely used screening instruments, they were the only profession trained in this.
6. Doctors experienced that they did not have time enough and also that it would interfere with the patients´ integrity to question them about alcohol consumption.
7. Biological markers and screening instruments were used frequently in most health centers, and more than 50% of them were offering Motivational interviews, Relapse prevention and Cognitive behavioral therapy to the patients.

Proposal for improvement area based on the results:

1. Continued education about early detection of hazardous according to the National Guidelines for managers, doctors and health coordinators.
2. Mandate issue for busines managers should be discussed, because prerequisites for implementation are dependent on the manager's mandate.
3. Tutorials, method support including training to question patients about their alcohol consumption may be implemented at network meetings.
4. Method Support / training in the use of screening instruments, lifestyle questionnaires and surveys that can facilitate on issues perceived to be taboo, such as the patient's alcohol consumption.
5. A policy that clarifies responsibilities, which should do what when it comes to alcohol issues.
6. Increase collaboration and delegation between health coordinators and doctors but also to another profession on some health centers, alcohol therapists.
7. Education / training / house training on the relationship between alcohol and somatic consequences.

The aim of this study was to highlight employees' experiences of interaction about persons who for some reason have come into contact withthe treatment of youth and/or substance abuse care in Sweden and Norway. Differences between ownership and regulation in Sweden andNorway on cooperation in drug treatment are discussed.The study was conducted using a qualitative approach, semi-structured interviews with employees in operations involved with adults andadolescents and their families. As the study was small in scope, four respondents in four operations in three counties, it is not possible to draw anygeneral conclusions. However there was found in the interviews, supported from literature, important prerequisites for collaboration concerningyouth with substance abuse problems is to have good understanding of and respect for other professions. The need of having an understanding ofeach other's knowledge, decisions skills, flexibility and the resources available in the operations has also emerged. There is an ambition to getsynergy in work but there are parts of the law preventing cooperating. Another preventing factor is that several actors often are involved aroundthe person who seeks help. Where collaboration works there are often personal relationships involved between collaboration partners. Thismakes collaboration vulnerable since they rely on private networks that are at risk of disappearing as soon as a key person leaves the service.

The main purpose of this study was to highlight young people with alcohol and drug problems and their experiences of social and pedagogical exclusion. The data collected consist of interviews, in turn obtained from Ungdok. Ungdok is a documentation system used by the Social Services. It aims at documenting young people’s own accounts of their alcohol and drug use and how it affects different aspects of their lives. The study’s focus was on how young people with a variety of substance use describe their experiences of exclusion in school settings. Initially the results were analyzed with the help of concepts that are used to identify various aspects of school difficulties, the significance of them, and what the consequences might be for the youngsters. The analysis also focuses on the elements of exclusion that the youngsters ascribe to the school setting, as well as peer relations, and their own family ties.

A large part of the interviewees, roughly 1/3 of  2169 young people with alcohol and drug problems, state that they have no school related problems, which perhaps could be attributed to a more normalized use of so-called party drugs, and/or cannabis. 2/3 of the interviewees however, state that they have experienced, or are experiencing school related problems. A lot of the young people whose accounts were used in this study state that their drug use was most prevalent in transition periods, even though alcohol use generally increase when adolescents reach adulthood. A finding of this study is that about half of the young people interviewed consider themselves unwanted or as failures. Another finding is that approximately 1/5 of the youngsters’ accounts of school related difficulties relate to ADHD or other neuropsychiatric difficulties or diagnoses. Physical illness is in a few cases also given as a reason for school related difficulties. Other problematic areas described by the young people relate to difficulties with concentration, and those are often described in terms of comorbidities or that the individual devalues him or herself.

The results of the study show that school related social exclusion appear on both a structural, interpersonal, as well as an individual level. Two distinct approaches also become apparent in the results. The first approach emphasizes that exclusion is the result of the school’s, or the educational institution’s failure to fully embrace inclusive practices. The second approach visible in the results takes a more individualistic view on exclusion, often resulting in the young person putting blame on him or herself for being the very reason they’re experiencing social, and/or pedagogical exclusion.

The study’s results raise questions as to what extent an individual child/young person can be expected to take responsibility for the parental level of education and the potential disadvantage this brings the young person. Other questions of interest that may be raised in relation to the results of this study is to what extent a child or young person can be expected to take responsibility for the potentially negative consequences of an unequal and/or segregated school system. Is it the education system, the school, or the pupils that ought to take the responsibility and action to guarantee the educational support that all pupils have the right to?

This study has contributed to the body of knowledge by providing knowledge of how young people with alcohol and drug problems describe their own experiences of school related difficulties, and to what extent these experiences in various degrees have contributed to a sense of social and pedagogical exclusion in school settings.