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Treatment repeaters: re-entry in care for clients with substance use disorder within the Swedish addiction treatment system
Umeå University, Faculty of Social Sciences, Department of Social Work.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

According to the regulations contained in the Social Services Act (SFS 2001:453), Swedish social services have a legal responsibility to provide support, care, and treatment for individuals with substance use problems.  This law mandate those who are responsible to provide treatment to motivate drug users to actively seek treatment on a voluntary basis, ensuring an end to their dependence on drugs. Studies have shown that although the treatment system largely focuses on promoting abstinence, about two-thirds of client’s relapse into substance use within one year after completing treatment. This dissertation focuses broadly on clients who repeatedly enter and use treatment for substance use disorders in the Swedish addiction treatment system. The aim of this thesis is to examine and identify the population groups who are repeated treatment users of the Swedish treatment system for substance use disorder, including both the voluntary treatment and compulsory care. This thesis was based on three national level databases. The results showed that clients with a higher degree of problems and problems in different areas of life also had an increased risk of having treatment for substance use disorder repeatedly. Clients who were older, men, reported more years of polydrug and alcohol use to intoxication, reported more compulsory care episodes for substance use, had ever been charged with crime, had ever been in inpatient mental health treatment, and had a higher ASI mental health symptom composite score, were significantly more likely to report more voluntary addiction treatment episodes. The strongest significant association with the number of treatment episodes was the number of compulsory treatment episodes for alcohol and drugs. Individuals who experienced prior compulsory care including mandatory treatment through LVU (law (1990:52)), been in prison, and had children mandated to out-of-home care, were more likely to have two or more entries in the compulsory care system for substance use disorder. In addition, this analysis showed that 59% of clients mandated to compulsory care dropped-out during their compulsory care episode, and that younger clients were significantly more likely to drop-out. Those who drop-out were significantly more likely to experience negative outcomes, i.e. additional sentence to compulsory care and higher risk of mortality.  A hierarchal logistic regression model also identified that individuals with riskier childhood conditions were more likely to have had repeated entries to compulsory care for substance use disorder. The indirect effects showed that a family history of substance use disorder and psychiatric problems are both associated with higher probability of institutional care as a child i.e. LVU, and that in turn, mandated childhood institutional care is related to repeated compulsory care intakes as an adult. Individuals who use treatment for substance use disorder repeatedly have a higher degree of problems i.e. an exposed and problematic group of individuals characterized by problem in several different areas of life. Growing up in a home environment with unfavorable conditions, mandated care before the age of 18 (LVU), compulsory care for substance use disorder as an adult, children taken into out-of-home care, and crime are the factors that are primarily associated with repeated treatment for substance use. A change in the view of treatment for clients in need of repeated use of treatment seems important, and access to adapted continuous care efforts are crucial to counteract the risk of relapse after a treatment episode of voluntary or compulsory care. Further, it seems important to motivate the client to complete the compulsory care without any deviation, since this seems to have positive effects on their substance use disorder.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2017. , 62 p.
Series
Studier i socialt arbete vid Umeå universitet : avhandlings- och skriftserie, ISSN 0283-300X ; 86
Keyword [en]
addiction treatment, treatment repeaters, substance use disorder, compulsory care, register database study, Sweden, chronic condition, drop-out, continuing care, bio-psycho-social
National Category
Social Work
Identifiers
URN: urn:nbn:se:umu:diva-141601ISBN: 978-91-7601-796-8 (print)OAI: oai:DiVA.org:umu-141601DiVA: diva2:1155719
Public defence
2017-12-01, Hörsal A, Samhällsvetarhuset, Umeå, 10:00 (Swedish)
Opponent
Supervisors
Available from: 2017-11-10 Created: 2017-11-09 Last updated: 2017-11-09Bibliographically approved
List of papers
1. Repeated addiction treatment use in Sweden: a national register database study
Open this publication in new window or tab >>Repeated addiction treatment use in Sweden: a national register database study
2014 (English)In: Substance Use & Misuse, ISSN 1082-6084, E-ISSN 1532-2491, Vol. 49, no 13, 1764-1773 p.Article in journal (Refereed) Published
Abstract [en]

Sweden has a free, universal addiction treatment system yet few studies examining utilization of treatment in this country. This study identified predisposing, enabling and need factors associated with history of number of voluntary addiction treatment episodes for a national sample of 12,009 individuals assessed for an alcohol and/or drug use disorder in Sweden. On average, people reported 4.3 prior treatment episodes. Linear regression methods identified that of predisposing factors older age and being male were associated with more voluntary addiction treatment episodes compared to younger and female clients; a higher Addiction Severity Index (ASI) employment score (an enabling factor) was associated with more voluntary addiction treatment episodes; and need factors including a history of inpatient mental health treatment, a higher ASI psychiatric score, a higher ASI alcohol score, higher levels of illict drug use, more compulsory addiction treatment episodes, a lower ASI legal score and history of criminal justice involvement were all associated with more voluntary addiction treatment episodes compared to their counterparts. There were no differences in number of treatment episodes by education or immigrant status. Implications: (1) Need is a key factor associated with more treatment use. (2) Further studies are needed to identify gender differences in access/use of treatment. (3) Given multiple treatment histories Swedish addiction treatment policy should reflect a chronic care model rather than an acute care model.

Place, publisher, year, edition, pages
London: Informa Healthcare, 2014
Keyword
addiction treatment, treatment repeaters, substance use disorder, compulsory treatment, Sweden, chronic care model
National Category
Psychology Psychiatry Substance Abuse
Identifiers
urn:nbn:se:umu:diva-93939 (URN)10.3109/10826084.2014.926932 (DOI)000343678600003 ()
Available from: 2014-10-01 Created: 2014-10-01 Last updated: 2017-11-09Bibliographically approved
2. Repeated entries to the Swedish addiction compulsory care system: A national register database study
Open this publication in new window or tab >>Repeated entries to the Swedish addiction compulsory care system: A national register database study
2015 (English)In: Evaluation and Program Planning, ISSN 0149-7189, E-ISSN 1873-7870, Vol. 49, 163-171 p.Article in journal (Refereed) Published
Abstract [en]

This study identified and described specific client groups who have repeated entries to the Swedish addiction compulsory care system. Specifically, through the use of baseline data from the Swedish government Staten’s Institutions Styrelse (SiS) database, for 2658 individuals who were assessed at their compulsory care intake interview by social workers in the national social welfare system between 2001 and 2009 the study identified the associations between specific predisposing, enabling and need characteristics and repeated addiction compulsory care entries. The logistic regression model identified that individuals whose children have been mandated to the child welfare system, who have experienced prior compulsory care including compulsory treatment through LVU (law (1990:52) with specific provision about care of young people under 18), and those who have been in prison are more likely to have two or more entries in the addiction compulsory care system compared to their counterparts. Individuals who have been mandated to compulsory care for their substance use disorder two or more times have significant multiple complex problems and repeated experiences of institutionalization. These individuals are a group in need of a well-coordinated and integrated system of aftercare services to reduce the likelihood of re-entry into addiction compulsory care. 

Place, publisher, year, edition, pages
Elsevier, 2015
Keyword
Compulsory care, Repeated entries, Substance use disorder, Sweden, Register database study
National Category
Social Work
Identifiers
urn:nbn:se:umu:diva-101176 (URN)10.1016/j.evalprogplan.2014.12.014 (DOI)000352663700018 ()25559948 (PubMedID)
Available from: 2015-03-24 Created: 2015-03-24 Last updated: 2017-11-09Bibliographically approved
3. Drop-out from the Swedish addiction compulsory care system
Open this publication in new window or tab >>Drop-out from the Swedish addiction compulsory care system
2015 (English)In: Evaluation and Program Planning, ISSN 0149-7189, E-ISSN 1873-7870, Vol. 49, 178-184 p.Article in journal (Refereed) Published
Abstract [en]

Drop-out of addiction treatment is common, however, little is known about drop-out of compulsory care in Sweden. Data from two national register databases were merged to create a database of 4515 individuals sentenced to compulsory care 2001-2009. The study examined (1) characteristics associated with having dropped out from a first compulsory care episode, (2) the relationship between drop-out and returning to compulsory care through a new court sentence, and (3) the relationship between drop-out and mortality. Methods: Multivariable logistic regression analysis was used to address Aim 1 and Cox proportional hazards regression modeling was applied to respond to Aims 2 and 3. Findings: Age and previous history of crime were significant predictors for drop-out. Clients who dropped out were 1.67 times more likely to return to compulsory care and the hazard of dying was 16% higher than for those who dropped-out. Conclusion: This study finds that 59% of clients assigned to compulsory care drop-out. Younger individuals are significantly more likely to drop-out. Those who drop out are significantly more likely to experience negative outcomes (additional sentence to compulsory care and higher risk of mortality). Interventions need to be implemented that increase motivation of youth to remain in compulsory care. 

Place, publisher, year, edition, pages
Elsevier, 2015
Keyword
Drop-out, Compulsory care, Mortality, Sweden
National Category
Social Work
Identifiers
urn:nbn:se:umu:diva-103153 (URN)10.1016/j.evalprogplan.2014.12.016 (DOI)000352663700020 ()25563530 (PubMedID)
Available from: 2015-05-29 Created: 2015-05-18 Last updated: 2017-11-09Bibliographically approved
4. The Importance of Risky Psychosocial Childhood for Repeated Addiction Compulsory Care as Adult
Open this publication in new window or tab >>The Importance of Risky Psychosocial Childhood for Repeated Addiction Compulsory Care as Adult
(English)Manuscript (preprint) (Other academic)
Keyword
Compulsory Care, Substance Use Disorder, Sweden, Psychosocial Childhood
National Category
Social Work
Identifiers
urn:nbn:se:umu:diva-141603 (URN)
Available from: 2017-11-09 Created: 2017-11-09 Last updated: 2017-11-09

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