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En dyster parentes – opiatregeln i svensk LARO-behandling 2010–2016
Jönköping University, School of Health and Welfare, HHJ, Dep. of Social Work. Jönköping University, School of Health and Welfare, HHJ. SALVE (Social challenges, Actors, Living conditions, reseach VEnue).ORCID iD: 0000-0002-1749-4727
2019 (Swedish)Doctoral thesis, comprehensive summary (Other academic)Alternative title
A dismal parenthesis – The opiate rule in Swedish opioid maintenance treatment 2010–2016 (English)
Abstract [en]

Opioids are well documented to arouse euphoria, relieve pain, and to have a high dependency potential. Opioid dependence is a serious chronic condition with a high risk of extensive worsened health, relapse and premature death.

Opioid maintenance treatment (OMT) is well researched and has strong scientific support. In Sweden, OMT over time was subjected to polarised and infected political debate and has been strictly regulated by the National Board of Health and Welfare (NBHW). During 2010–2016 NBHW redefined the diagnostic concept of “opiate dependence” in the regulation SOSFS 2009:27. Dependence to only three opioids: heroin, opium or morphine, could give eligibility to OMT (here called the “opiate rule”). The purpose stated was to prevent those dependent to other opioides, e.g. buprenorphine,from receiving OMT. Applicants with severe opioid dependence were thereby divided into two subgroups: those with “opiate” dependence related to heroin, morphine or opium, and those with opioid dependence who lacked documentation in relation to the three opiates. The question is whether there were differences between these groups concerning problem severity or substance-related diagnostics that could justify differences in access to OMT?

A population (n = 127) actualised for OMT during 2005-2011 in Jönköping County is studied regarding severity of problems, diagnostics and trajectories in and out of treatment. In order to provide precise drug use data, a cognitive tool for taking anamnestic information, called the Drug List, was developed.

In Study I, using the Addiction Severity Index, the two groups were found to be quite similar in severity of health problems, social situation and drug problems, including overdoses and injections.

In Study II, the Drug List was found to be superior to a traditional way of taking anamnestic data, more sensitive and giving more precise data, without taking more time. Validity was shown in relation to faked drugs.

In Study III, using a structured diagnostic interview, ADDIS, with the Drug List, showed that both two groups qualified for severe opioid dependence, that opiates and other opioids had contributed equally to the development of opioid dependency, and that the two groups also had similar additional substance dependence problems.

Study IV investigated how “the opiate rule” affected practice by interviewing representatives of OMT clinics as well as a representative of a users’ association. The regulation created dilemmas for clinics as well as for users. Users developed a strategy of getting "negative merits" for being eligible to OMT. Clinicians developed strategies to find ways “around” the regulation in order to admit patients in OMT.

Study V followed those who had applied for OMT and found four trajectory subgroups – those denied OMT, those discharged, those readmitted, and those who remained in treatment. The study provides evidence for a more positive development being related to more involvment in OMT concerning health, social situation as well as substance use problems. Being denied or discharged is related to increased risks of a negative development.

The thesis conclude that there was no support for dividing applicants according to “the opiate rule”. The purpose of top-down control using regulations, is to guarantee uniform and knowledge-based care. In this case the regulation had negative effects in these respects, increasing risks for the applicants, and lost credibility from the profession. The opiate rule in SOSFS 2009:27 is therefore a dismal parenthesis in the history of OMT in Sweden, and could be studied to prevent similar mistakes in the future.

Place, publisher, year, edition, pages
Jönköping: Jönköping University, School of Health and Welfare , 2019. , p. 152
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 095
Keywords [en]
opiates, opioids, opioid maintenance treatment, methadone, buprenorphine, regulation, National Board of Health and Welfare
Keywords [sv]
opiater, opioider, opioidberoende, buprenorfin, metadon, läkemedelsassisterad behandling, föreskrift, Socialstyrelsen
National Category
Social Work
Identifiers
URN: urn:nbn:se:hj:diva-43443ISBN: 978-91-85835-94-2 (print)OAI: oai:DiVA.org:hj-43443DiVA, id: diva2:1303605
Public defence
2019-05-10, Forum Humanum, Hälsohögskolan, Jönköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2019-04-10 Created: 2019-04-10 Last updated: 2019-04-10Bibliographically approved
List of papers
1. Type of opioid dependence among patients seeking opioid substitution treatment: Are there differences in background and severity of problems?
Open this publication in new window or tab >>Type of opioid dependence among patients seeking opioid substitution treatment: Are there differences in background and severity of problems?
2016 (English)In: Substance Abuse Treatment, Prevention, and Policy, ISSN 1747-597X, E-ISSN 1747-597X, Vol. 11, no 1, p. 1-8, article id 23Article in journal (Refereed) Published
Abstract [en]

Background: The study explores differences and similarities in background and problem severity among those seeking Opioid Substitution Treatment (OST), comparing those who primarily had misused "opiates", e.g. heroin, morphine and opium, with those who primarily had misused other opioids.

Methods: Patients (n=127) assessed for possible admittance in OST are compared based on the Addiction Severity Index. Two groups based on primary type of opioid misused are compared (opiates vs. other opioids).

Results: In the global severity ratings there were no significant differences between the groups other than tautological artefacts concerning heroin. There were few specific differences between the groups. The opiate group more often had Hepatitis C and more often had legal problems related to financing their misuse. Injection of drugs was the main method of administration in both groups, i.e. 90 % for mostly opiates vs. 75 % for mostly other opioids. A great majority in both groups, 96 % vs. 91 %, had misused most other types of drugs. Both groups were found to have severe problems in all areas investigated.

Conclusions: The study demonstrates great similarities in problem severity among those seeking OST, both those who primarily had misused opiates and those who primarily had misused other opioids.

Keywords
Opiates, Opioid Substitution Treatment, Opioid-related disorders, Opioids
National Category
Substance Abuse
Identifiers
urn:nbn:se:hj:diva-31175 (URN)10.1186/s13011-016-0066-1 (DOI)000379329800001 ()27401680 (PubMedID)2-s2.0-84979655919 (Scopus ID)
Funder
Futurum - Academy for Health and Care, Jönköping County Council, Sweden, FUTURUM-342201
Available from: 2016-08-08 Created: 2016-08-08 Last updated: 2019-04-10Bibliographically approved
2. Drug list as a cognitive support to provide detailed information on a patient's drug use: A comparison of two methods within the assessment of drug misuse and dependence
Open this publication in new window or tab >>Drug list as a cognitive support to provide detailed information on a patient's drug use: A comparison of two methods within the assessment of drug misuse and dependence
2016 (English)In: Substance Use & Misuse, ISSN 1082-6084, E-ISSN 1532-2491, Vol. 51, no 11, p. 1470-1476Article in journal (Refereed) Published
Abstract [en]

Background: It is important to identify the type of drugs a patient has used, especially when polydrug misuse has increased and new drugs and patterns of misuse are quickly spread. Objectives: In order to acquire sufficient information about drug use, an effective and simple form of mapping is needed.

Methods: Persons actualized for Opioid Substitution Treatment (n = 135) were interviewed about their drug-history in a two-stage model. First, they were asked to write down the drugs misused, and dot those injected with a felt pen. Second, they were asked to do the same on a drug list provided as a cognitive support. For a subsample of 50 persons, the drug list included four fictive drugs to evaluate possible over-reporting.

Results: The use of a drug list did not take longer than the traditional way of using open questions, i.e. about 5–8 minutes. Using a drug list gave a cognitive support resulting in a much higher proportion/number of reported drugs. The majority, 97%, used more than one drug. None of the patients who were given the drug list that included fictive drug names reported having used any of them. The respondents reported 43 additional substances to the 125 given on the list which improve our knowledge of the drug scene.

Conclusions/importance: Using a drug-list was superior to open questions; it does not take more time and provides additional, clinically relevant information than open questions. Using a drug-list also gives improved knowledge of new drugs entering the local drug scene.

Keywords
cognitive support, diagnostic instruments, drug anamnesis, opioid substitution therapy, Substance use disorders
National Category
Substance Abuse
Identifiers
urn:nbn:se:hj:diva-31258 (URN)10.1080/10826084.2016.1186697 (DOI)000382325500008 ()27355832 (PubMedID)2-s2.0-84976385510 (Scopus ID)
Available from: 2016-08-16 Created: 2016-08-16 Last updated: 2019-04-10Bibliographically approved
3. Opiates versus other opioids – are these relevant as diagnostic categorizations?
Open this publication in new window or tab >>Opiates versus other opioids – are these relevant as diagnostic categorizations?
2017 (English)In: Heroin Addiction and Related Clinical Problems, ISSN 1592-1638, Vol. 19, no 6, p. 39-48Article in journal (Refereed) Published
Abstract [en]

Background:

For more than three decades, the international diagnostic systems have used the term ‘opioids’, including opiates, yet research publications continue to use an older terminology. In 2010, new Codes of Statutes for “opiate replacement therapy” (ORT) was brought into effect in Sweden, stating that only those “dependent on opiates” – explicitly described as heroin, morphine or opium – were eligible. Those addicted to other opioids were then denied access. This study examines the relevance of the distinction of opiates vs. other opioids. Are there differences in the severity of opioid dependence or concerning other substance-related diagnoses?

Methods:

Ninety-nine individuals participated: 1) the opiate group (n = 69), and 2) the other opioids group (n=30). Structured interviews covered the ICD-10 criteria of nine different types of addictive substances. For opioids, questions were asked separately in relation to opiates versus other opioids.

Results:

The two groups fulfilled the criteria for opioid dependence to the same extent, with most participants meeting all six criteria, so indicating a severe opioid dependence problem. Both opiates and other opioids had contributed to their development of opioid dependence, and both groups, to the same high degree, showed comorbidity affecting other dependence conditions.

Conclusions:

This study reveals that the two categories of opioids used contribute to the development of opioid dependence and that the term ‘opioids’ can be suitably used to convey a unitary concept in diagnostic terms. There was no support for treating the two groups differently. The study calls for more stringent use of terminology in accordance with the international diagnostic systems.

Place, publisher, year, edition, pages
Associazione per l'Utilizzo delle Conoscenze Neuroscientifiche a fini Sociali, 2017
Keywords
Maintenance treatment; Buprenorphine; opioid; opiate; dependence; diagnosis; nosology
National Category
Substance Abuse Pharmacology and Toxicology
Identifiers
urn:nbn:se:hj:diva-37848 (URN)000416893800005 ()2-s2.0-85035240103 (Scopus ID)
Available from: 2017-11-09 Created: 2017-11-09 Last updated: 2019-04-10Bibliographically approved
4. Opiatregeln i konflikt med vetenskap,yrkesetik och klinisk erfarenhet: Hur en föreskrift för LARO hanterades ipraktiken
Open this publication in new window or tab >>Opiatregeln i konflikt med vetenskap,yrkesetik och klinisk erfarenhet: Hur en föreskrift för LARO hanterades ipraktiken
(Swedish)Manuscript (preprint) (Other academic)
National Category
Social Work
Identifiers
urn:nbn:se:hj:diva-43442 (URN)
Note

Manuskript under granskning.

Available from: 2019-04-10 Created: 2019-04-10 Last updated: 2019-04-10
5. Opioid maintenance treatment: trajectories in and out of treatment
Open this publication in new window or tab >>Opioid maintenance treatment: trajectories in and out of treatment
2019 (English)In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 73, no 1, p. 24-30Article in journal (Refereed) Published
Abstract [en]

Problem: Although efficacy studies of opioid maintenance treatment (OMT) have shown evidence of treatment benefits, there is still need for studies on its effectiveness in natural clinical processes. This study investigates the development in health, substance use and social conditions of those who applied for OMT, including those denied access or discharged.

Method: First, persons assessed for admittance in 2005–2011 (n = 127) were categorized into four trajectory groups based on whether they were admitted or denied (n = 19), discharged (n = 31), readmitted (n = 21) or had been undergoing OMT without interruption (n = 56). Second, 99 of these, the analytical sample, were interviewed at follow-up using (a) the Addiction Severity Index (ASI) for seven problem-areas and housing, and (b) self-rated change in 11 problem areas. The ASI was compared to baseline interviews after 55 months (mean). Third, outcomes within groups was studied in relation to alternative interventions.

Results: Within the analytical sample, those denied OMT showed no improvements at group level, those discharged had some improvements, more if readmitted than if not and those with uninterrupted OMT showed the most comprehensive improvements. Those outside OMT, denied and discharged, had considerable mortality risks related to ongoing drug use, especially in lack of well-planned alternative interventions.

Conclusion: Improvements strongly relate to access to OMT. This study underscores that access to OMT improves the situation in all areas investigated and decreases the risk for drug-related death. It underscores the importance of two major risk situations, i.e. being denied OMT and being discharged.

Place, publisher, year, edition, pages
Taylor & Francis, 2019
Keywords
Opioid maintenance treatment, drop-outs, treatment outcome, treatment process
National Category
Social Work
Identifiers
urn:nbn:se:hj:diva-42623 (URN)10.1080/08039488.2018.1539120 (DOI)000466445300004 ()30636473 (PubMedID)2-s2.0-85060035376 (Scopus ID)HOA HHJ 2019 (Local ID)HOA HHJ 2019 (Archive number)HOA HHJ 2019 (OAI)
Available from: 2019-01-14 Created: 2019-01-14 Last updated: 2019-06-14Bibliographically approved

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