Standards for opioid use disorder care: An assessment of Nordic approaches

Reasons for not entering opioid agonist treatment: A survey among high-risk opioid users in Finland

Aims: To characterise and understand the untreated high-risk opioid user population in Finland, and to determine the reasons why these people do not enter treatment. Methods: The study setting was a half-year cross-sectional survey in Finland during 2021-2022. An electronic questionnaire with 24 structured questions was concluded in 16 needle exchange units. Participants were opioid-dependent people without opioid agonist treatment (OAT), and they answered the survey voluntarily and anonymously. Results: Of the 167 respondents, 62% were men, 53% were aged ≤34 years, 66% had used opioids for >6 years, and 78% used drugs intravenously (IV) daily. The most used opioid (95%) was buprenorphine. Most respondents used opioids as self-medication for withdrawal symptoms (75%), or to treat psychological symptoms (59%) or pain (43%). Of them, 70% also used other substances for recreational purposes. The most common named reasons to stay outside OAT were as follows: seeking treatment is too difficult (37%); treatment is too binding (36%); and fear of actions from authorities (23%). Conclusions: For opioid-dependent respondents who would be eligible for OAT in Finland, treatment awareness is limited. These high-risk opioid users also think that the treatment would be too binding. In conclusion, there is a need for increase in general information about, accessibility to, acceptance for and individualisation of OAT.

Long-acting injectable depot buprenorphine from a harm reduction perspective in patients with ongoing substance use and multiple psychiatric comorbidities: a qualitative interview study

BACKGROUND

Long-acting injectable depot buprenorphine may increase access to opioid agonist treatment (OAT) for patients with opioid use disorder in different treatment phases. The aim of this study was to explore the experiences of depot buprenorphine among Swedish patients with ongoing substance use and multiple psychiatric comorbidities.

METHOD

Semi-structured qualitative interviews were conducted with OAT patients with experience of depot buprenorphine. Recruitment took place at two OAT clinics with a harm reduction focus, specializing in the treatment of patients with ongoing substance use and multiple comorbidities. Nineteen participants were included, 12 men and seven women, with a mean age of 41 years (range 24-56 years), and a mean of 21 years (5-35 years) of experience with illicit substance use. All participants had ongoing substance use and psychiatric comorbidities such as ADHD, anxiety, mood, psychotic and eating disorders. Interviews were transcribed verbatim. Thematic content analysis was conducted both manually and using qualitative data analysis software.

RESULTS

Participants reported social benefits and positive changes in self-perception and identity. In particular, depot buprenorphine contributed to a realization that it was possible to make life changes and engage in activities not related to substance use. Another positive aspect that emerged from the interviews was a noticeable relief from perceived pressure to divert OAT medication, while some expressed the lack of income from diverted oral/sublingual OAT medication as a negative, but still acceptable, consequence of the depot buprenorphine. Many participants considered that the information provided prior to starting depot buprenorphine was insufficient. Also, not all patients found depot buprenorphine suitable, and those who experienced coercion exhibited particularly negative attitudes towards the medication.

CONCLUSIONS

OAT patients with ongoing substance use and multiple psychiatric comorbidities reported clear benefits of depot buprenorphine, including changes in self-perception which has been theorized to play an important role in recovery. Clinicians should consider the specific information needs of this population and the extensive diversion of traditional OAT medications in this population to improve the treatment experience and outcomes. Overall, depot buprenorphine is a valuable treatment option for a population in need of harm reduction and may also contribute to psychological changes that may facilitate recovery in those with the greatest need.

Patient perspectives on depot buprenorphine treatment for opioid addiction – a qualitative interview study

Background

Recently developed buprenorphine depot injections have the potential to reduce risk for diversion and misuse, and to increase adherence with fewer visits for supervised intake. However, it is unclear how patients perceive this new form of medication. The purpose of this study was to explore patients’ experiences of depot injections and their reasons for continuing, discontinuing, or declining depot injection treatment.

Methods

We conducted semi-structured qualitative interviews with 32 people, 14 of whom had ongoing depot injection treatment, 11 who had discontinued depot-injections and switched to other medication and seven who had declined treatment with depot formulations. Interviews were transcribed, coded, and analysed using NVivo, based on this overall stratification into three participant groups.

Results

The main categories relate to the effects and side effects of the depot formulation, social and practical factors, psychological benefits and disadvantages, and interactions with treatment staff. Social and practical factors were of importance for choosing depot formulations, such as increased freedom and their making it easier to combine treatment with work and family life, as well as psychological advantages including “feeling normal”. Initial withdrawal symptoms that resolved themselves after a number of injections were reported by most participants. Reliable information and patient-staff relationships characterized by trust helped patients to cope with these initial problems. Those who discontinued treatment often did so near the beginning of the treatment, reporting withdrawal symptoms and insufficient effects as the main reasons. Coercion and insufficient information contributed to a negative pharmaceutical atmosphere at one of the clinics, which may have adversely influenced perceptions of depot formulations and decreased willingness to accept and continue treatment.

Conclusions

Buprenorphine depot injections may have social, practical, and psychological benefits compared to other formulations. However, depot injections are not perceived as an attractive option by all patients. Trust, consistent and adequate information, and awareness of the implications of the pharmaceutical atmosphere should be considered when introducing new medications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-022-00474-2.

Predicting the Onset of Opioid Use Disorder in the Swedish General Population

OBJECTIVE

Given the public health importance of opioid use disorder (OUD), we sought to understand better its risk predictors in the Swedish general population.

METHOD

We examined the Swedish population, born 1950-1970 (n = 2,092,359), and followed through 2018. Using Cox, logistic, and co-sibling models, we explored associations between a wide range of putative risk factors and a first onset of OUD--assessed through medical, criminal, and pharmacy registers--in the entire cohort and in the cohort wherein prior cases of drug use disorder (DUD) were censored.

RESULTS

OUD was predicted by the following four risk factor domains: (a) externalizing syndromes, especially prior non-opioid DUD; (b) psychopathology; (c) psychosocial factors, including social class and immigrant and marital status; and (d) serious injuries and pain diagnoses. When predicting OUD as the first form of DUD, the importance of pain diagnoses as a predictor increased. Co-sibling analyses suggested that the association of some of these risk factors with OUD onset was likely largely causal, whereas others were a mixture of causal effects and familial confounding. An aggregate risk score from these individual risk factors had reasonable receiver operating characteristic (ROC) curve performance.

CONCLUSIONS

OUD is a multifactorial syndrome for which risk can be meaningfully predicted by prior externalizing syndromes, internalizing and psychotic psychopathology, indicators of psychosocial status, and predictors of pain diagnoses. Some important differences were seen in the prediction of any OUD onset versus OUD onset as the first form of DUD. Much of the effect of these predictors appear, in co-sibling analyses, to likely reflect causal influences.

Opioid related deaths in Norway in 2000-2019

AIMS

The aim of the study is to present autopsy-based findings of the most prevalent opioids in overdose deaths in Norway from 2000 to 2019, as such data are lacking in the current literature.

METHODS

Data on cause of death obtained from the Norwegian Cause of Death Registry (NCoDR) were linked with forensic toxicological results from forensic autopsies.

RESULTS

From year 2000 the annual numbers of overdose deaths decreased, specifically during 2000-2003, thereafter a relatively stable annual number was observed. Opioids were detected in 93% of the cases. Heroin related deaths have decreased, whereas medical opioids for pain treatment have increased with time. Men in their early 40's dominate the overall numbers of deaths, but significantly different sex patterns emerge when studying the specific drugs. During the past 20 years, the mean age at overdose death has increased by 10 years (from 33 to 43 years). Overdose deaths without any illicit drugs present at autopsy have increased in recent years. These deaths, where only potentially prescription medications were detected, were more common among women and with higher age.

CONCLUSIONS

In Norway during the past 20 years, we observe a dynamic shift in overdose deaths caused by heroin and illicit drugs, to include a gradually increasing trend of overdose deaths from pill based pain medications and also methadone and buprenorphine. This warrants a shift in preventive responses, as the target groups differ.

The "black box" of treatment: Patients' perspective on what works in opioid maintenance treatment for opioid dependence

BACKGROUND

A lack of conceptual modeling of how the components of opioid maintenance treatment (OMT) for opioid dependence (OD) work causes it to occasionally be labeled the "black-box" of treatment. This study had a two-fold objective: First, to analyze which factors related to OMT for OD contribute to the abstinence of problematic use of non-prescribed opioids and sustain recovery, from the patients' perspective; second, to understand which changes OMT produced in the individuals' lives might significantly contribute to relapse prevention.

METHODS

We used qualitative methods of design, inquiry, and analysis from a convenience sample of 19 individuals in a Swedish treatment setting.

RESULTS

All the participants reported previous cycles of problematic use of non-prescribed opioids and other non-prescribed psychoactive substances, treatment, abstinence, recovery, and relapse before starting the current OMT program. During the pre-treatment stage, specific events, internal processes, and social environments enhanced motivation toward abstinence and seeking treatment. During the treatment stage, participants perceived the quality of the human relationships established with primary social groups as important as medication and the individual plan of care in sustaining recovery. From the participants' perspective, OMT was a turning point in their life course, allowing them a sense of self-fulfillment and the reconstruction of personal and social identity. However, they still struggled with the stigmatization produced by a society that values abstinence-oriented over medication-assisted treatments.

CONCLUSION

OMT is not an isolated event in individuals' lives but rather a process occurring within a specific social context. Structural factors and the sense of acceptance and belonging are essential in supporting the transformation. Treatment achievements and the risk for relapse vary over time, so the objectives of the treatment plan must account for characteristics of the pre-treatment stage and the availability and capacity of individuals to restructure their social network, besides the opioid maintenance treatment and institutional social care.

Methadone-related deaths among youth and young adults in Sweden 2006-15

AIMS

To identify methadone-related deaths and determine the prevalence among youth and young adults in Sweden 2006-15.

DESIGN, SETTING AND PARTICIPANTS

National retrospective registry study comparing data from all forensic autopsy examinations and toxicology cases involving methadone during 2006-15 in individuals aged 15-29 years with police records, previous pharmaceutical prescriptions and health-care episodes.

MEASUREMENTS

Multinomial logistic regression. To assess the factors contributing to the deaths, we compared individuals with and without previous substance use treatment and opioid use-related diagnoses with regard to previous opioid agonist treatment (OAT), psychiatric care and previous pain medication. To assess the circumstances of deaths, we analyzed the presence of other drugs and other factors at time of death.

FINDINGS

We identified 269 methadone-related deaths, and the rate increased during the study period. Seventy-two (27%) cases had not previously received substance use treatment, 112 (42%) had received treatment but had no opioid use-related diagnosis and 85 (32%) had received treatment and had an opioid use-related diagnosis. In total, only 10 individuals had been prescribed methadone during the year before death. Prescriptions of benzodiazepines (60%), antidepressants (62%) and opioids for pain (22%) the year before death were common. Most deaths occurred during sleep with a time lag from ingestion of methadone.

CONCLUSION

Prescription opioid- and methadone-related deaths increased in the group aged 15-29 years in Sweden between 2006 and 2015. Exposure to non-prescribed methadone and prescribed benzodiazepines, antidepressants and opioids for pain appears to be common in drug-related deaths in youth and young adults in Sweden.